Prior Authorization Pharmacist
Actalent, Houston, TX, United States
Job Title
Clinical Pharmacist – Prior Authorization (Remote)
Job Description
This role focuses on reviewing and adjudicating prescription medication prior authorization requests using clinical criteria, regulatory standards, and evidence-based guidelines. You will evaluate the medical necessity, safety, and appropriateness of requested therapies, communicate clear decisions and recommendations to healthcare professionals, and contribute to continuous improvement of clinical and operational processes in a fully remote work setting.
Responsibilities
Review and adjudicate prior authorization requests for prescription medications in accordance with plan policies, clinical criteria, FDA labeling, and evidence-based guidelines.
Evaluate the medical necessity, safety, and appropriateness of requested therapies for a wide range of clinical conditions.
Apply utilization management criteria, including step therapy protocols, quantity limits, and formulary alternatives, to ensure appropriate and cost-effective use of medications.
Communicate authorization decisions clearly, professionally, and in a timely manner to prescribers, pharmacists, and internal stakeholders.
Provide clinical recommendations and suggest alternative therapy options when requests do not meet approval criteria, supporting optimal patient care.
Document all clinical decisions accurately, thoroughly, and consistently within authorization systems and related platforms.
Ensure compliance with state and federal regulations, including CMS, NCQA, and URAC standards, throughout the prior authorization process.
Participate in denial reviews, appeals, and peer‑to‑peer consultations as needed to support fair and evidence‑based outcomes.
Support the development, review, and maintenance of clinical criteria and formulary policies to keep them aligned with current evidence and regulations.
Collaborate with medical directors, nurses, pharmacy technicians, and operations teams to improve authorization workflows and turnaround times.
Monitor trends in prior authorization requests, identify opportunities for process improvement, and support quality initiatives aimed at enhancing efficiency and clinical outcomes.
Essential Skills
Active and unrestricted Pharmacist license in at least one of the following states: Indiana (IN), Kansas (KS), Pennsylvania (PA), Georgia (GA), or New Mexico (NM).
Experience practicing as a pharmacist with strong knowledge of prescription medications and clinical pharmacotherapy.
Ability to interpret and apply plan policies, clinical criteria, FDA labeling, and evidence-based guidelines to prior authorization decisions.
Strong clinical judgment to evaluate medical necessity, safety, and appropriateness of requested therapies.
Proficiency in applying utilization management criteria such as step therapy, quantity limits, and formulary alternatives.
Excellent written and verbal communication skills to convey authorization decisions and clinical recommendations clearly and professionally.
Strong attention to detail and accuracy in documenting clinical decisions within authorization systems.
Working knowledge of relevant regulations and standards, including CMS, NCQA, and URAC requirements.
Ability to collaborate effectively with interdisciplinary teams, including medical directors, nurses, pharmacy technicians, and operations staff.
Organizational and time‑management skills to handle multiple prior authorization requests and meet turnaround time expectations in a remote environment.
Additional Skills & Qualifications
Experience in prior authorization, utilization management, managed care, or similar clinical review settings.
Familiarity with formulary management and development or maintenance of clinical criteria and policies.
Comfort working with electronic authorization systems and clinical documentation tools.
Experience participating in denial reviews, appeals, and peer‑to‑peer consultations.
Experience in supporting quality improvement initiatives and process optimization within pharmacy or healthcare operations.
Work Environment
This is a work‑from‑home position that allows you to perform all responsibilities remotely. The role requires reliable internet access, a professional remote workspace, and the ability to manage your time effectively while meeting established turnaround times and quality standards.
Job Type & Location
Contract to Hire position based out of Houston, TX.
Pay and Benefits
Pay range: $60.00 - $70.00/hr.
Medical, dental & vision
Critical Illness, Accident, and Hospital
401(k) Retirement Plan – Pre‑tax and Roth post‑tax contributions available
Life Insurance (Voluntary Life & AD&D for the employee and dependents)
Short and long‑term disability
Health Spending Account (HSA)
Transportation benefits
Employee Assistance Program
Time Off/Leave (PTO, Vacation or Sick Leave)
Application Deadline
This position is anticipated to close on May 6, 2026.
Actalent is an equal opportunity employer.
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Clinical Pharmacist – Prior Authorization (Remote)
Job Description
This role focuses on reviewing and adjudicating prescription medication prior authorization requests using clinical criteria, regulatory standards, and evidence-based guidelines. You will evaluate the medical necessity, safety, and appropriateness of requested therapies, communicate clear decisions and recommendations to healthcare professionals, and contribute to continuous improvement of clinical and operational processes in a fully remote work setting.
Responsibilities
Review and adjudicate prior authorization requests for prescription medications in accordance with plan policies, clinical criteria, FDA labeling, and evidence-based guidelines.
Evaluate the medical necessity, safety, and appropriateness of requested therapies for a wide range of clinical conditions.
Apply utilization management criteria, including step therapy protocols, quantity limits, and formulary alternatives, to ensure appropriate and cost-effective use of medications.
Communicate authorization decisions clearly, professionally, and in a timely manner to prescribers, pharmacists, and internal stakeholders.
Provide clinical recommendations and suggest alternative therapy options when requests do not meet approval criteria, supporting optimal patient care.
Document all clinical decisions accurately, thoroughly, and consistently within authorization systems and related platforms.
Ensure compliance with state and federal regulations, including CMS, NCQA, and URAC standards, throughout the prior authorization process.
Participate in denial reviews, appeals, and peer‑to‑peer consultations as needed to support fair and evidence‑based outcomes.
Support the development, review, and maintenance of clinical criteria and formulary policies to keep them aligned with current evidence and regulations.
Collaborate with medical directors, nurses, pharmacy technicians, and operations teams to improve authorization workflows and turnaround times.
Monitor trends in prior authorization requests, identify opportunities for process improvement, and support quality initiatives aimed at enhancing efficiency and clinical outcomes.
Essential Skills
Active and unrestricted Pharmacist license in at least one of the following states: Indiana (IN), Kansas (KS), Pennsylvania (PA), Georgia (GA), or New Mexico (NM).
Experience practicing as a pharmacist with strong knowledge of prescription medications and clinical pharmacotherapy.
Ability to interpret and apply plan policies, clinical criteria, FDA labeling, and evidence-based guidelines to prior authorization decisions.
Strong clinical judgment to evaluate medical necessity, safety, and appropriateness of requested therapies.
Proficiency in applying utilization management criteria such as step therapy, quantity limits, and formulary alternatives.
Excellent written and verbal communication skills to convey authorization decisions and clinical recommendations clearly and professionally.
Strong attention to detail and accuracy in documenting clinical decisions within authorization systems.
Working knowledge of relevant regulations and standards, including CMS, NCQA, and URAC requirements.
Ability to collaborate effectively with interdisciplinary teams, including medical directors, nurses, pharmacy technicians, and operations staff.
Organizational and time‑management skills to handle multiple prior authorization requests and meet turnaround time expectations in a remote environment.
Additional Skills & Qualifications
Experience in prior authorization, utilization management, managed care, or similar clinical review settings.
Familiarity with formulary management and development or maintenance of clinical criteria and policies.
Comfort working with electronic authorization systems and clinical documentation tools.
Experience participating in denial reviews, appeals, and peer‑to‑peer consultations.
Experience in supporting quality improvement initiatives and process optimization within pharmacy or healthcare operations.
Work Environment
This is a work‑from‑home position that allows you to perform all responsibilities remotely. The role requires reliable internet access, a professional remote workspace, and the ability to manage your time effectively while meeting established turnaround times and quality standards.
Job Type & Location
Contract to Hire position based out of Houston, TX.
Pay and Benefits
Pay range: $60.00 - $70.00/hr.
Medical, dental & vision
Critical Illness, Accident, and Hospital
401(k) Retirement Plan – Pre‑tax and Roth post‑tax contributions available
Life Insurance (Voluntary Life & AD&D for the employee and dependents)
Short and long‑term disability
Health Spending Account (HSA)
Transportation benefits
Employee Assistance Program
Time Off/Leave (PTO, Vacation or Sick Leave)
Application Deadline
This position is anticipated to close on May 6, 2026.
Actalent is an equal opportunity employer.
#J-18808-Ljbffr