Prior Authorization Pharmacist - Temporary

Moda Health; Portland (OR); Remote; USD 104,000 - 132,000; Full time

Benefits offered by this job

Medical, Dental, Vision & Pharmacy

PTO and Holidays

401k - Matching

Job summary

Moda Health is seeking a skilled pharmacist to join its clinical pharmacy team in a temporary, remote role focusing on prior authorization functions. You will make coverage determinations and process appeal requests using established criteria and plan designs, impacting patient care.

The position offers a pay range reflected publicly and may be hourly depending on location. Oregon licensure within 60 days is required, with opportunities to support multiple lines of business from a remote setting.

Qualifications

• Active, unrestricted Oregon Pharmacist license or eligible within 60 days.
• Strong communication with healthcare providers and internal teams.
• Commitment to service and professional conduct.
• Works well under pressure with interruptions and shifting priorities.
• Adheres to HR policies, Code of Conduct, and confidentiality.

Responsibilities

• Evaluate medication requests for coverage and perform clinical reviews against guidelines and formularies.
• Provide prior authorization pharmacist coverage for rotating weekends and holidays.
• Offer on-call support for urgent medication requests and assist pharmacy, appeals, and customer services teams.
• Perform coverage determinations for all lines of business for both pharmacy and medical medications.
• Participate in appeals and grievances with clinical expertise and review of complaints.
• Conduct medical literature evaluations to support decisions.
• Perform peer-to-peer reviews with providers when requested.
• Recommend improvements to coverage criteria and medication edits based on utilization.
• Provide timely, clear drug information responses to members, clients, and staff with documentation.
• Organize workload and prioritize tasks to meet departmental standards.
• Support quality assurance and ongoing improvement initiatives.
• Stay updated on communications and processes and apply to daily duties.
• Assist staff training and development as required.
• Review and maintain applicable clinical pharmacy policies and procedures.
• Perform other related duties as assigned.

Skills

Oregon license

Communication skills

Interpersonal skills

Pressure management

Policy adherence

Education

Pharm.D.

Job description

About Moda

Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together. Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Let’s be better together.

Let’s do great things, together!

About Moda

Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together. Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Let’s be better together.

Position Summary

We are currently seeking a skilled and dedicated pharmacist to join our clinical pharmacy team. In this role, you will have the exciting opportunity to focus on the vital prior authorization functions of our work. Your primary responsibilities will involve making coverage determinations and completing appeal requests, using your clinical expertise to provide coverage decisions based on established criteria, guidelines, and specific plan design. You will be part of a dynamic environment where you can make a significant impact on patient care and contribute to the overall success of our healthcare organization.

This is a temporary role that is a WFH.

Pay Range

$103,893.01 - $132,461.48 annually (depending on experience)

• This role may be classified as hourly (non-exempt) depending on the applicant's location. Actual pay is based on qualifications. Applicants who do not exceed the minimum qualifications will only be eligible for the low end of the pay range.

Benefits

• Medical, Dental, Vision & Pharmacy
• PTO and Company Paid Holidays
• 401k - Matching

Required Skills, Experience & Education

• Current active and unrestricted Oregon Registered Pharmacist license, or eligible for Oregon licensure which is to be obtained within 60 days of hire date
• Effective communication and interpersonal skills to interact with healthcare providers, internal teams, and external stakeholders
• Commitment to service, organizational values, and professionalism through appropriate conduct and demeanor always
• Works well under pressure with frequent interruptions and shifting priorities
• Follow the company HR policies, Code of Conduct, and all department policies and procedures including protecting confidential company, employee, and customer information

Preferred Skills

• Doctor of Pharmacy degree (Pharm.D.)
• Experience in clinical therapeutics for specialty drugs
• Two to three years of managed care experience

Primary Functions

• Evaluate medication requests for coverage (e.g., prior authorization reviews, non-formulary requests, step therapy exceptions), conducting thorough clinical reviews and assessing their compliance with established clinical guidelines, formularies, and policies
• Provide prior authorization pharmacist coverage for rotating weekends and holidays
• Provide ad hoc or on call support for urgent medication requests and provide internal pharmacist support to the pharmacy team, appeals unit, and customer services department
• Perform coverage determination reviews for all lines of business (i.e., commercial, exchange, government) for pharmacy and medical (physician-administered or home infusion) medications
• Participate in the appeals and grievances process by providing clinical expertise and reviewing medication-related appeals and complaints
• Complete medical literature evaluation using primary, secondary, and tertiary drug resources to support coverage decision-making and recommendations
• Perform peer-to-peer reviews with providers when requested
• Make recommendations on medication edit improvements (e.g., programming) and coverage criteria, based on utilization and findings during coverage determination reviews
• Provide clear, comprehensive, and timely responses to requests for drug information to members, clients, providers, and internal staff via detailed and thorough documentation within coverage determinations, appeal documentation, and email inquiries
• Organize workload, set priorities, complete assignments in a timely manner and utilize resources appropriately while complying with department program standards
• Participate in and support department quality assurance and ongoing improvement practices
• Remain current on all communications and updated processes relayed through multiple team communication channels and apply to daily duties and responsibilities
• Support staff training and development as required
• Review, update, and maintain applicable policies and procedures related to clinical pharmacy services
• Performs all other related duties as assigned by departmental managers

Working Conditions

• Office environment with extensive close PC and keyboard use, constant sitting, and frequent phone communication. Must be able to navigate multiple computer screens. A reliable, high-speed, hard-wired internet connection required to support remote or hybrid work. Must be comfortable being on camera for virtual training and meetings. Work in excess of standard workweek, including evenings and occasional weekends, to meet business need.

Together, we can be more. We can be better.

Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status or any other status protected by law. This is applicable to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absences, compensation, and training.

For more information regarding accommodations, please direct your questions to Kristy Nehler & Danielle Baker via our [e-mail] email.