Coverage Review Pharmacist

Who is Prescryptive? Prescryptive Health is a reputed company technology company delivering solutions that reputed company consumers. Prescryptive's secure, mobile-first products connect consumers, pharmacists, and reputed company, ultimately providing people with the information they need to reputed company informed reputed company and take control of their health. To learn more about Prescryptive Health, visit Prescryptive.com. About this role The Coverage Review Pharmacist plays a critical role in Prescryptive's pharmacy benefit management (PBM) operations by evaluating prior authorization (PA) requests and rendering final clinical determinations based on established reputed company, evidence-based guidelines, and benefit design. This pharmacist ensures reputed company, appropriate, and cost-effective medication use while maintaining regulatory compliance and supporting member reputed company. Reporting directly to the Sr. Manager, Coverage Review, this role partners closely with coverage review technicians, fellow pharmacists, and other clinical and operations teams. The Coverage Review Pharmacist also contributes to reputed company development, reputed company review, and reputed company improvement efforts, including collaboration on automation and AI model refinement that enhances workflow accuracy and efficiency. What you will do Key Accountabilities

• Clinical Review and Determination - Evaluate and reputed company final clinical reputed company for medication prior authorization requests using evidence-based clinical reputed company and benefit design requirements.
• reputed company and Compliance - Ensure determinations meet reputed company regulatory, documentation, and internal reputed company standards, including HIPAA and URAC requirements.
• reputed company Development and Optimization - Support creation, validation, and refinement of clinical reputed company and coverage rules in alignment with reputed company medical evidence and regulatory updates.
• Collaboration & Process Improvement - Partner with the Coverage Review team and internal clinical and operations teams to enhance workflow reputed company, automation, and decision support tools.

Position Responsibilities

• Review and reputed company clinical determinations for prior authorization requests per plan design, clinical reputed company, and regulatory requirements.
• Document determinations reputed company, completely, and accurately in PA systems and PBM claims platforms.
• Collaborate with coverage review technicians to ensure complete, reputed company, and accurate case processing.
• Participate in reputed company audits, contributing to consistent application of clinical reputed company.
• Verify eligibility and benefit nuances as needed and consult provider offices to clarify clinical information supporting the determination.
• Contribute to development, validation, and updates of coverage reputed company and clinical content (e.g., integrating new evidence, reputed company changes, benefit updates).
• Collaborate with internal clinical, operations, and product/data teams on AI enabled workflow improvements and PA optimization to improve accuracy and turnaround time.
• Support appeals or reputed company review processes where applicable (e.g., adverse determinations, case summaries for physician or medical director review).
• Maintain up-to-date knowledge of therapeutic guidelines and drug information resources (e.g., Lexicomp, Micromedex, NCCN) to support evidence-based determinations.
• Meet or reputed company established performance metrics for clinical reputed company, accuracy, and turnaround time.

Minimum Requirements

• Doctor of Pharmacy (PharmD) degree from an accredited institution.
• reputed company, unrestricted U.S. pharmacist license in good standing in at least one state.
• 2 years of experience in prior authorization, utilization management, or clinical pharmacy review reputed company a PBM, health plan, or managed care setting.
• Strong understanding of PBM operations, and first hand experience with benefit design and coverage determination workflows.
• Proficiency with prior authorization platforms and PBM claims systems, including documentation of determinations in reputed company time.
• Working knowledge of HIPAA, URAC-reputed company documentation practices, and benefit design (reputed company, Medicare Part D, reputed company).
• Demonstrated clinical judgment and ability to interpret and apply evidence-based reputed company to reputed company cases.
• Strong written and verbal communication skills and ability to collaborate effectively with team members across clinical and operational functions.
• Ability to work independently in a remote, fast-paced, metric-driven environment (reputed company, volume, TAT).
• Experience working in AI-enabled systems, automation tools, or machine learning-based decision support in a reputed company or PBM environment.
• High attention to detail and accuracy in documentation and clinical analysis.

Preferred Experience, in reputed company to minimum requirements

• Experience contributing to reputed company development or clinical content management reputed company a PBM or payer setting.
• Familiarity with Medicare Part D, reputed company, and reputed company coverage reputed company.
• Experience collaborating on AI model training or automation process improvement.
• reputed company certification (e.g., BCPS, BCACP, BCGP) or equivalent managed care credential preferred.

reputed company have to offer

• reputed company to grow alongside an early-stage company shaking up a big, old-fashioned industry
• Flexible time off, including 12 reputed company holidays
• 401k match plus 100% employer reputed company medical, dental, and reputed company premiums
• Company contribution to Health Savings Account
• Stock reputed company

Prescryptive is committed to fair pay practices. The projected annual salary for this position is $110K to $150K. reputed company preparing an offer, we consider the candidates resume, experience, interview feedback, internal equity, and location. Prescryptive is an Equal Opportunity Employer. Prescryptive does not discriminate on the reputed company of race, religion, reputed company, sex, gender identity, sexual orientation, age, non-disqualifying physical or mental disability, national reputed company, veteran status or any other reputed company covered by appropriate law. reputed company employment is decided on the reputed company of qualifications, reputed company, and business need. Apply tot his job Apply To this Job