SpecialtyRx
Prior Authorization Pharmacist
Morton Grove, Illinois•Full-time
$60 - $62 hourly
$60 - $62 hourly
About the Job
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Competitive Pay | Stable Schedule | Career Growth.
Our Company:
SpecialtyRx is a Long-Term Care pharmacy providing pharmaceutical services to long-term care facilities, assisted living communities, and hospice providers. SpecialtyRx takes pride in delivering personalized care and quality pharmacy services to the residents and communities we serve.
Position: Prior Authorization Pharmacist.
Position Summary:
We are seeking a knowledgeable, detail-oriented, and patient-focused Prior Authorization Pharmacist to join our Long-Term Care Pharmacy team in Illinois. This position plays a critical role in reviewing medication coverage requirements, supporting prior authorization submissions, resolving insurance claim rejections, and ensuring patients receive timely access to prescribed medications.
The Prior Authorization Pharmacist will work closely with insurance providers, prescribers, long-term care facilities, hospice providers, and internal pharmacy teams to address coverage restrictions, formulary requirements, medication approvals, and reimbursement challenges.
The ideal candidate has strong clinical judgment, a thorough understanding of pharmacy benefit plans, and experience with prior authorizations, insurance billing, and medication coverage reviews. Long-term care pharmacy, hospice medication management, and Medicare Part D experience are preferred.
Responsibilities:
- Review medication orders and assess insurance coverage requirements, formulary restrictions, and prior authorization criteria.
- Evaluate prior authorization requests for clinical appropriateness, medical necessity, and compliance with applicable payer requirements.
- Prepare, submit, and follow up on prior authorization requests to state-sponsored insurance plans, private insurers, Medicare Part D plans, and other applicable payers.
- Review insurance claim rejections and determine appropriate clinical or administrative steps to facilitate resolution.
- Communicate with prescribers and healthcare providers to obtain supporting clinical information, documentation, and clarification needed for authorization requests.
- Work directly with insurance companies and pharmacy benefit managers regarding medication coverage, overrides, rejected claims, and authorization status.
- Research alternative coverage options and formulary alternatives when medications are denied or restricted, collaborating with prescribers when clinically appropriate.
- Assist with urgent medication access issues by prioritizing time-sensitive authorization requests and communicating delays to appropriate parties.
- Support medication coverage coordination for hospice patients, including researching payer requirements and addressing coverage questions related to hospice and non-hospice medications.
- Collaborate with long-term care facilities, hospice teams, and internal pharmacy departments to resolve medication access and reimbursement issues.
- Review patient insurance information and eligibility records to support accurate billing and appropriate claim processing.
- Document authorization decisions, payer communications, clinical reviews, and follow-up activities accurately in the appropriate systems.
- Assist with insurance audits, billing reviews, and the resolution of outstanding authorization-related issues.
- Maintain current knowledge of applicable pharmacy regulations, payer policies, formulary requirements, and prior authorization procedures.
- Follow established pharmacy policies, patient confidentiality requirements, and applicable federal and Illinois regulations.
- Perform additional duties as assigned by pharmacy management.
Qualifications:
- Doctor of Pharmacy (Pharm.D.) or Bachelor of Science in Pharmacy from an accredited institution.
- Active Illinois pharmacist license in good standing, required.
- Previous experience in pharmacy prior authorizations, insurance billing, utilization management, or medication coverage review preferred.
- Long-term care pharmacy experience preferred.
- Experience with hospice medication coverage and coordination preferred.
- Familiarity with Medicare Part D, Medicaid, commercial insurance plans, pharmacy benefit managers, and payer authorization requirements preferred.
- Knowledge of pharmacy claim rejection codes, formulary restrictions, coverage determinations, and insurance overrides.
- Strong clinical assessment skills and the ability to evaluate medication requests for appropriateness and medical necessity.
- Excellent written and verbal communication skills, including the ability to communicate effectively with prescribers, insurance representatives, facility staff, and pharmacy colleagues.
- Strong analytical, organizational, and problem-solving skills.
- Proficiency in pharmacy management systems, electronic documentation, and Microsoft Office applications.
- Ability to manage multiple authorization requests and prioritize urgent medication access needs in a fast-paced environment.
- Ability to work independently while collaborating effectively with a multidisciplinary team.
- Strong attention to detail, sound professional judgment, and a commitment to patient safety and quality care.
What We Offer:
- Competitive pay based on experience.
- Consistent scheduling based on departmental needs.
- Health, dental, and vision insurance.
- Group Life Insurance and Short-Term Disability.
- Paid time off and paid holidays.
- 401(k) with company match.
- Professional development and ongoing training opportunities.
- Career advancement opportunities within SpecialtyRx.
Equal Employment Opportunity (EEO) Statement:
SpecialtyRx, Inc. is committed to employing a diverse workforce. We recruit and retain talented individuals without regard to race, color, religion, sex, gender, age, national origin, marital status, disability, veteran status, sexual orientation, gender identity, or any other status protected by applicable federal, state, or local law, including the Illinois Human Rights Act.
EO/Minorities/Females/Disabled/Veterans.
About SpecialtyRx:
SpecialtyRx is proud to be a beacon for inclusion, collaboration, and diversity. Everyone cares in the same language, and we draw from each community to be for each community.