Remote Appeals Pharmacist – Prior Authorization & Coverage

Capital Rx Inc.; New York (NY); Remote; USD 120,000 - 135,000; Full time

Job summary

Judi Health in the United States is seeking a Pharmacist to review clinical coverage determinations and appeals across Commercial and Medicare lines. You will assess medical necessity and use guidelines to render decisions.

The role requires a licensed pharmacist, at least 1 year of appeals experience, and strong communication. Remote work from a secure home office is supported; salary range is $120,000–$135,000 USD.

Qualifications

• Active unrestricted pharmacist license required.
• 1+ years prior authorization review or appeals experience.
• Strong oral and written communication skills; ability to work independently in a remote setting.

Responsibilities

• Evaluate and review appeals to render coverage determinations based on clinical criteria.
• Collaborate with Medical Directors to provide clinical data for reviews.
• Interpret clinical guideline criteria to render approvals/denials on appeals.
• Perform peer-to-peer reviews with providers when requested.
• Perform literature evaluation to support decision-making.
• Document prior authorization and appeals thoroughly.
• Make determinations in line with medical necessity and guidelines within turnaround times.
• Maintain quality and productivity while meeting turnaround time requirements.
• Stay updated on communications and policies; apply to daily responsibilities.
• Ensure HIPAA compliance and high-quality customer care.

Skills

Pharmacist license

Communication skills

Microsoft Office

Micromedex

Lexicomp

Clinical Pharmacology

Tools

Microsoft Office Suite

Micromedex

Lexicomp

Clinical Pharmacology

Job description

Judi Health in the United States is seeking a Pharmacist to review clinical coverage determinations and appeals across Commercial and Medicare lines. You will assess medical necessity and use guidelines to render decisions.

The role requires a licensed pharmacist, at least 1 year of appeals experience, and strong communication. Remote work from a secure home office is supported; salary range is $120,000–$135,000 USD.