Clinical Review Pharmacist
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Job Description
Clinical Review Pharmacist reviewing prior authorizations and appeals for SmithRx’s technology-driven pharmacy benefit management platform. Supporting members, providers, pharmacies, and clinical programs remotely.
Responsibilities:
- Review and make timely, evidence-based decisions on prior authorizations and appeals using clinical guidelines and benefit criteria
- Ensure compliance with federal, state, and internal regulations across applicable lines of business
- Accurately document clinical decisions and maintain thorough records in accordance with URAC/NCQA utilization review standards
- Provide support to members, prescribers, and pharmacies by responding to clinical inquiries
- Stay current with clinical prescribing guidelines, internal policies, and regulatory changes
- Follow internal procedures, job aids, and HIPAA guidelines to protect patient privacy and data security
- Identify and report potential fraud, waste, and abuse
- Support training and development of team members
- Assist leadership with special projects, process improvements, and operational initiatives
Requirements:
- Doctor of Pharmacy (PharmD.) or Bachelor of Science in Pharmacy (B.S. Pharm) from an ACPE-accredited school of pharmacy
- Active, unrestricted, pharmacist license in state of residence
- Minimum of 2 years of pharmacy practice experience
- Strong communication, writing, and organizational skills
- Ability to manage multiple priorities in a high-volume, metric-driven environment
- General understanding of drug information, clinical guidelines, formulary design, and utilization management strategies
- Flexible and adaptable to changes
- Availability to work after hours, weekends, and holidays on a rotating or fixed schedule
- Preferred: One year of prior authorization or utilization management experience
- Preferred: One year experience in managed care or pharmacy benefit management (PBM)
- Preferred: Direct experience conducting prior authorization reviews, clinical appeals, formulary exceptions, step therapy evaluations, and quantity limit reviews
- Preferred: Experience in Google Workspace (Gmail, Docs, Sheets, and Drive)
Benefits:
- Time off programs
- Medical insurance
- Dental insurance
- Vision insurance
- Mental health support
- Paid parental leave
- Life insurance
- Disability insurance
- 401(k)
- Potential eligibility for bonuses, commissions, or equity
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