Remote Pharmacist I – Medicaid Prior Authorization

ACTalent; United States; Remote; USD 63,000 - 89,000; Full time

Job summary

ACTalent is seeking a fully remote Pharmacist I to review Utilization Management requests for Medicaid members, including formulary exceptions, prior authorizations, and step therapy. You will apply criteria and clinical judgment, documenting decisions clearly, and communicating with prescribers via fax, phone, and electronic systems.

This role targets pharmacists transitioning from retail to managed care. Ideal candidates have PharmD or PharmD/B.S.

Qualifications

• Doctor of Pharmacy (PharmD) or Bachelor of Science in Pharmacy degree.
• Current pharmacist license in good standing with the applicable State Board of Pharmacy.
• Minimum of 2 years of experience as a licensed pharmacist in retail, managed care, or clinical pharmacy.
• Experience with pharmacy benefits management or prior authorization processes.
• Ability to make independent clinical decisions within defined criteria and professional standards.
• Strong ability to prioritize tasks and manage multiple cases or projects simultaneously.
• Results-driven mindset with a demonstrated drive to deliver outcomes and meet performance metrics.
• Self-motivated and able to work independently without constant direction or feedback.

Responsibilities

• Review Utilization Management requests for Medicaid members, including formulary exceptions, prior authorization, step therapy, and quantity limit exception requests.
• Apply client-specific criteria, clinical guidelines, and professional judgment to determine whether prior authorization requests should be approved or denied.
• Document all clinical decisions clearly and accurately in the appropriate systems, ensuring compliance with internal policies and regulatory requirements.
• Communicate with prescribers and providers by phone, fax, and electronic systems to clarify information, obtain additional clinical details, and explain determinations, handling approximately 510 calls per day.
• Use pharmacy benefits management tools and systems to process requests efficiently while maintaining high quality and attention to detail.
• Manage a steady workflow of electronic and fax submissions, prioritizing cases based on urgency, complexity, and established turnaround times.
• Independently make clinical decisions within defined criteria and elevate complex or ambiguous cases as appropriate.
• Maintain productivity, accuracy, and quality metrics as defined by leadership, including production volume, work quality, and attendance standards.
• Adapt to evolving policies, procedures, and criteria, incorporating updates into daily decision-making and documentation.
• Participate in required training sessions and apply new knowledge to review specialized cases when opportunities arise (such as oncology, hepatitis C, and other complex conditions).
• Collaborate with internal teams and leadership to support consistent application of criteria and best practices across the Utilization Management function.
• Provide professional, courteous, and timely communication to providers and internal stakeholders to support efficient case resolution.
• Maintain confidentiality of member information and adhere to all applicable privacy and security regulations.
• Potentially cross-train and support other departments, such as Medication Therapy Management or Call Center Counseling, if opportunities are available and performance criteria are met.
• Work assigned shifts, including evenings and rotating weekends, and comply with scheduling requirements, blackout periods, and holiday coverage expectations.

Skills

PharmD

Pharmacy degree

Pharmacist license

Retail experience

Managed care experience

Prior authorization

PBM experience

Independent decision making

Typing 35 wpm

Education

PharmD or B.S. in Pharmacy

Job description

ACTalent is seeking a fully remote Pharmacist I to review Utilization Management requests for Medicaid members, including formulary exceptions, prior authorizations, and step therapy. You will apply criteria and clinical judgment, documenting decisions clearly, and communicating with prescribers via fax, phone, and electronic systems.

This role targets pharmacists transitioning from retail to managed care. Ideal candidates have PharmD or PharmD/B.S.