Senior Pharmacy Prior Authorization & AI Quality Reviewer

Empathy; United States; On-site; USD 82,656 - 165,312; Full time

Job summary

mpathic.ai seeks a seasoned professional to validate AI-driven prior authorization outputs and specialty medication access decisions. You will review real-world scenarios, assess medical necessity criteria, and provide structured feedback to enhance patient safety and policy compliance.

Applicants should have deep PBM experience, strong English communication, and meticulous attention to detail to improve AI-generated recommendations for payers, prescribers, and care teams in a fast-evolving

Qualifications

• 5+ years in pharmacy prior authorization, specialty medication access, or PBM-related field.
• Deep understanding of formularies, step therapy, and payer authorization criteria across commercial/government plans.
• Experience with specialty pharmacy platforms, PBM systems, or medication access programs.
• Strong written English; ability to explain complex clinical and policy concepts clearly.
• Exceptional attention to detail and sound judgment when reviewing docs and AI outputs.

Responsibilities

• Evaluate AI-generated prior authorization recommendations for accuracy, completeness, and payer alignment.
• Review specialty medication requests using formularies, step therapy, and PBM policies.
• Assess supporting clinical documentation and whether AI outputs meet medical necessity criteria.
• Apply structured evaluation guidelines to annotate model responses and identify errors/gaps.
• Provide clear, actionable feedback to improve AI performance in complex pharmacy workflows.
• Assess AI outputs involving coordination with prescribers, specialty pharmacies, and payers.
• Bring real-world knowledge of specialty medication access to shape safer, more trustworthy healthcare AI.

Skills

Prior Authorization

PBM Expertise

Clinical Documentation

English Proficiency

Job description

mpathic.ai seeks a seasoned professional to validate AI-driven prior authorization outputs and specialty medication access decisions. You will review real-world scenarios, assess medical necessity criteria, and provide structured feedback to enhance patient safety and policy compliance.

Applicants should have deep PBM experience, strong English communication, and meticulous attention to detail to improve AI-generated recommendations for payers, prescribers, and care teams in a fast-evolving