Remote Clinical Pharmacy Review Specialist Prior Auth

0100 PHP Administrative; New Mexico; Hybrid; USD 28,000 - 47,000; Full time

Job summary

Presbyterian Healthcare Services is seeking a Clinical Pharmacy Review Specialist for a remote-based role in New Mexico. You will support clinical case reviews, prepare data for coverage determinations, prior authorizations, and member reimbursements.

The role requires PTCB certification, GED or higher, and PBM/Medicare Part D experience. Strong communication and HIPAA knowledge are essential, with duties spanning documentation, claims review, and MTM assistance.

Qualifications

• GED or High School diploma required.
• Certified Pharmacy Technician (PTCB) required.
• Experience with pharmacy benefits management, health insurance or prescription benefits preferred.

Responsibilities

• Perform first-level review and evaluation of prior authorization requests.
• Prepare and research clinical data for coverage determinations and appeals.
• Enter and interpret documentation in the claims processing system.
• Communicate benefit coverage and formulary information to members and providers.
• Assist Pharmacist in reviewing member medication regimens and MTM.
• Meet deadlines with accuracy and urgency.

Skills

Clinical pharmacy

Prior authorization

Medicare Part D

HIPAA compliance

Member communication

Pharmacy benefits

Education

GED or High School diploma

PTCB certification

Tools

Claims processing system

Job description

Presbyterian Healthcare Services is seeking a Clinical Pharmacy Review Specialist for a remote-based role in New Mexico. You will support clinical case reviews, prepare data for coverage determinations, prior authorizations, and member reimbursements.

The role requires PTCB certification, GED or higher, and PBM/Medicare Part D experience. Strong communication and HIPAA knowledge are essential, with duties spanning documentation, claims review, and MTM assistance.