Remote Clinical Pharmacy Review Specialist

Presbyterian Healthcare Services; Santa Fe (NM); Remote; USD 28,000 - 47,000; Full time

Benefits offered by this job

Medical benefits

Dental

Vision

Disability insurance

Life insurance

Voluntary benefits

Job summary

Presbyterian Healthcare Services is seeking a Clinical Pharmacy Review Specialist for a remote role based in New Mexico. The position supports clinical data review for coverage determinations, prior authorizations, and appeals within the Pharmacy Services Department.

The role involves reviewing prior authorization requests, gathering information, and coordinating with clinical pharmacists for second-level review while ensuring HIPAA compliance and timely processing.

Qualifications

• Experience with pharmacy benefits management, health insurance or prescription benefits.
• Medicare Part D and Medicaid program experience is preferred.
• Retail pharmacy experience is preferred.

Responsibilities

• Perform first-level review of prior authorization requests for appropriateness and policy compliance.
• Request additional information from prescribers to establish medical necessity for second-level review.
• Enter and interpret documents for prior authorization in the claims system.
• Communicate benefit coverage and formulary information to members, providers, and staff.
• Assist pharmacists with medication reviews and therapy management tasks.

Skills

Pharmacy benefits management

Medicare Part D knowledge

Customer service

Drug information

Education

GED / High School diploma

Certified Pharmacy Technician-PTCB

Job description

Presbyterian Healthcare Services is seeking a Clinical Pharmacy Review Specialist for a remote role based in New Mexico. The position supports clinical data review for coverage determinations, prior authorizations, and appeals within the Pharmacy Services Department.

The role involves reviewing prior authorization requests, gathering information, and coordinating with clinical pharmacists for second-level review while ensuring HIPAA compliance and timely processing.