Prior Authorization Pharmacist: Managed Care Expert

US Tech Solutions; Rhode Island; On-site; USD 90,000 - 115,000; Full time

Job summary

US Tech Solutions is seeking a Pharmacist - Prior Authorization Advisor to evaluate PA requests using clinical criteria and plan design. You will interact with physicians and members, support the Prior Auth team, and provide on-call after-hours coverage as needed.

The role requires a PharmD with managed care experience, an active state pharmacist license, and strong PBM knowledge. You will work within our supported systems to ensure timely decisions and high-quality reviews.

Qualifications

• PharmD with managed care experience required.
• Minimum 6 months prior authorization experience.
• Must have PBM familiarity and relevant managed care knowledge.

Responsibilities

• Evaluate and review all prior authorization requests and render coverage determinations based on clinical criteria and plan design. Includes verifying insurance coverage and eligibility, interpreting clinical guideline criteria, consulting physicians and other healthcare providers, and appropriately utilizing clinical knowledge and resources while complying with department protocols.
• Collaborates with technicians and prior authorization team members to process referrals and perform clinical assessments per agreed criteria, handling inbound/outbound calls to facilitate PA requests and resolve escalations.
• Maintains professional and technical knowledge of drug/disease states for Specialty and Non-Specialty Pharmacy programs within the Commercial Specialty line.
• Performs other related projects and duties, including attending training sessions and providing on-call and after-hours pharmacist availability.

Skills

Prior Authorization

Managed Care Knowledge

PBM Experience

Education

PharmD degree

Job description

US Tech Solutions is seeking a Pharmacist - Prior Authorization Advisor to evaluate PA requests using clinical criteria and plan design. You will interact with physicians and members, support the Prior Auth team, and provide on-call after-hours coverage as needed.

The role requires a PharmD with managed care experience, an active state pharmacist license, and strong PBM knowledge. You will work within our supported systems to ensure timely decisions and high-quality reviews.