Prior Authorization Pharmacist - Capital Rx

Location: Remote (For Non-Local) or Hybrid (Local to NYC area)

Position Summary:

A Prior Authorization (PA) Pharmacist at Capital Rx performs day to day clinical pharmacy functions including prior authorization and appeal reviews, override requests and inbound and outbound member and provider education calls while following medical necessity and contract criteria.

Position Responsibilities:

• Perform day to day clinical pharmacy functions including prior authorization and appeal reviews, override requests, and inbound and outbound member and provider education calls.
• Make clinical decisions in accordance with medical necessity and contract criteria
• Perform scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations to providers
• Communicate effectively with providers and members to promote positive health outcomes
• Provide backup support to call center team as required
• Review pharmacy claims data for proactive outreach and intervention
• Support staff training and development as required
• Identify and monitor inappropriate trends in care to improve quality and cost effectiveness
• Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements
• Supports quality improvement programs/projects as required (~5% of time)
• Provide support for clinical programs including creation and maintenance of prior authorization criteria guidelines and decision trees
• Work with business and clinical partners as needed
• Ability to work in a fast-paced environment with shifting priorities
• Work on scheduled shift – please see schedule details under minimum qualifications section for required working hours
• Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance

Minimum Qualifications:

• Active, unrestricted, pharmacist license required
• Bachelors or Doctorate of Pharmacy Degree required
• 2+ years of pharmacy practice experience required
• Managed care or PBM pharmacy experience required
• Medicare Part D experience preferred
• Proficient in Microsoft office Suite with emphasis on Microsoft Excel
• Available to work during peak season from January-March (no planned extended vacations will be approved)
• Available to work a shift from either 11am-8pm EST or 2pm-11pm EST that will be assigned to you, along with rotating weekends

Base Salary: $120,000 - $125,000

Nothing in this position description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.

About Capital Rx

Capital Rx is a full-service pharmacy benefit manager (PBM) and pharmacy benefit administrator (PBA), advancing our nation’s electronic healthcare infrastructure to improve drug price visibility and patient outcomes. As a Certified B Corp™, Capital Rx is executing its mission through the deployment of JUDI®, the company’s cloud-native enterprise health platform, and a Single-Ledger Model™, which increases visibility and reduces variability in drug prices. JUDI connects every aspect of the pharmacy ecosystem in one efficient, scalable platform, servicing millions of members for Medicare, Medicaid, and commercial plans. Together with its clients, Capital Rx is reimagining the administration of pharmacy benefits and rebuilding trust in healthcare.

Capital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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