Remote Prior Authorization Pharmacist Operations Advisor

Job Title: Remote Prior Authorization Pharmacist Operations Advisor Pay: $53 an hr | Bi-weekly Job Type: Remote Start date: 10/27/25 Shift Options: • Shifts available (Sun-Thurs or Tues-Sat): 10:30am-7pm CST 11am-7:30pm CST 11:30am-8pm CST Training dates: October 27th - December 12th, 2025; training time: 8am to 4:30pm CST Remote Prior Authorization Pharmacist Operations Advisor Overview: • 1.) Evaluate and review all prior authorization requests and render coverage determinations based on clinical criteria and plan design. Includes verifying insurance coverage and eligibility, interpreting clinical guideline criteria, consulting physicians and other healthcare providers, and appropriately utilizing clinical knowledge and resources while complying with department protocols. One of the crucial responsibilities is to guarantee that the decisions regarding cases are conveyed promptly and efficiently to all the healthcare providers, health plans/employers, patients, and other healthcare professionals following agreed-upon approval & denial management processes. (60%) • 2.) Collaborates with the technicians and prior authorization team members to process referrals, including answering clinical questions and collecting appropriate clinical/medical data needed to perform clinical assessments and reviews as per the health plan/employer-agreed criteria within the designated service level agreements. Performs and handles inbound and outbound phone calls with technicians, prior authorization team members, physicians, healthcare providers, and/or patients to facilitate prior authorization requests, answer inquiries, and/or resolve escalations. (25%) • 3.) Maintains professional and technical knowledge of drug and disease states for the Specialty and Non-Specialty Pharmacy programs administered within the Commercial Prior Authorization and Case Review Unit (CRU) line of business. (10%) • 4.) Performs other related projects and duties as assigned, including attending training sessions and development meetings, and providing on-call and after-hours pharmacist availability as needed. (5%) • Essential Functions: • 1. Regular and predictable attendance • 2. Colleague will be required to work mandatory overtime/extended work week when needed • 3. Colleague will be required to travel when needed • 4. Comply with departmental, company, state, and federal requirements when processing all information to ensure accuracy of information being provided to internal and external customers. • 5. Adhere to all policies and procedures • 6. Attend on going training and development meetings Remote Prior Authorization Pharmacist Operations Advisor Qualifications: • Prior experience with prior authorization (PA) reviews or clinical case review in a high-volume or production setting—look for direct experience processing PA requests, ideally with commercial or specialty pharmacy, and strong documentation of meeting service level agreements (SLAs) or production targets. Those with Retail experience only – are not excluded and are welcome to apply as we have had many successful applicants from retail. Demonstrated ability to multitask using multiple technology platforms and clinical resources—seek candidates who highlight comfort with multitasking, proficiency with Microsoft Office (especially Excel and Word), and using multiple clinical and administrative systems at once. Strong communication and collaboration skills in cross-functional teams—prioritize resumes that show effective written and verbal communication, experience working with both clinical and non-clinical staff, and handling phone-based interactions with providers and patients. Remote Prior Authorization Pharmacist Operations Advisor Benefits: • Benefits are available to full-time employees after 90 days of employment and include health, optical, dental, life, and short-term disability insurance. • A 401(k) with a company match is available for full-time employees with 1 year of service on our eligibility dates. How to Apply: If you are interested in this position, please apply OR submit your resume to: Saw Hlaing | [email protected] | 412-790-5425 Apply tot his job