Prior Authorization Pharmacist

JOB SUMMARY

The Prior Authorization Pharmacist is responsible for the clinical review of high-cost, specialty, injectable, and non-formulary medication requests within a healthcare Management Services Organization (MSO). This role ensures that coverage determinations comply with applicable federal and California regulations, evidence-based clinical guidelines, and internal policies. Working collaboratively with Medical Directors, the Pharmacy & Therapeutics (P&T) Committee, and Medical Management leadership, the PA Pharmacist validates adverse determinations, supports utilization management decisions, and serves as a clinical resource for internal and external stakeholders.

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: Doctor of Pharmacy (Pharm.D.) from an accredited college or university.

Experience

Minimum: Demonstrated clinical pharmacy experience with prior authorization review, utilization management, or managed care pharmacy functions.

Preferred: Experience reviewing specialty, injectable, or high-cost medications within a managed care, MSO, or health plan environment.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Certification(s)

Active, current, and unrestricted Pharmacist License issued by the California State Board of Pharmacy required.

Skills, Knowledge & Abilities

• Advanced knowledge of clinical pharmacology, disease state management, and evidence-based medicine.
• Strong analytical and critical-thinking skills with the ability to exercise independent clinical judgment.
• Excellent written and verbal communication skills.
• Strong organizational skills and ability to manage competing priorities in a deadline-driven environment.
• Proficiency with electronic medical records, utilization management systems, and standard pharmacy software.
• Ability to maintain confidentiality and comply with HIPAA and regulatory requirements.

Physical, Mental & Environmental Requirements

The physical, mental, and environmental demands described below are representative of those required to perform the essential functions of the job, with or without reasonable accommodation. This role is primarily sedentary and requires prolonged periods of sitting, frequent computer use, and repetitive data entry. The employee must be able to read clinical documentation and electronic records, communicate clearly via telephone and written correspondence, and maintain focus and accuracy while reviewing complex clinical information. Occasional travel and driving may be required for trainings or meetings.