FairosRx Prior Authorizations Pharmacist (Full-Time)

The OccuNet Company is an innovative company striving to reduce the cost of healthcare. We are a passionate group of people that care about affordable access to healthcare without sacrificing experience. We strive to make healthcare more intelligent, streamlined, and cost-effective. We offer industry-leading capabilities on negotiations-driven levers to contain rising healthcare costs while taking an experience-centric approach improving the health and well-being of those we serve. We pride ourselves on our tight knit culture based on the ‘outward mindset’ philosophy, emphasizing empathy, mutual respect, and seeing each other as “whole people.” We have an ambitious vision and are growing quickly. We are seeking team members who are excited about our growth, seeking to thrive in a fast-paced environment, and enthusiastic about developing their skills and career alongside us.

Job Description

Job Title: Prior Authorization Pharmacist

Department: Clinical (Operations)

Reports To: Sr Vice President of Clinical
Position Summary

The Prior Authorization Pharmacist is responsible for the clinical review and evaluation of pharmacy prior authorization requests to ensure appropriate medication use in accordance with member benefits, evidence-based clinical criteria, and client-specific coverage policies. This position supports high-quality, cost-effective pharmaceutical care by making timely coverage determinations, identifying clinically appropriate therapeutic alternatives, coordinating appeals, and collaborating with prescribers, members, and internal stakeholders.

The Prior Authorization Pharmacist also provides clinical leadership to the pharmacy operations team by supporting utilization management initiatives, developing and maintaining clinical criteria, identifying cost-saving opportunities, and driving continuous quality improvement across clinical programs.
Essential Duties and Responsibilities
Clinical Review and Utilization Management

- Review and evaluate prior authorization requests in accordance with member benefit plans, clinical guidelines, client policies, and regulatory requirements.

- Complete prior authorization reviews within established turnaround time requirements while maintaining high standards of clinical quality and accuracy.

- Apply evidence-based clinical criteria to determine medical necessity and appropriateness of requested drug therapies.

- Identify opportunities for therapeutic optimization and cost-effective medication management while maintaining clinical efficacy and patient safety.

- Collaborate with prescribing providers to recommend clinically appropriate, cost-effective formulary alternatives when applicable.

- Provide clinical recommendations that promote appropriate medication utilization and adherence to formulary management strategies.

Appeals and Clinical Consultation

- Coordinate the clinical review of appeals related to pharmacy benefit determinations.

- Communicate coverage decisions and clinical rationale to providers, members, pharmacy staff, and other stakeholders.

- Receive and initiate telephone calls with providers and members to obtain additional clinical information or provide clinical consultation regarding pharmacy benefit decisions.

- Serve as a clinical resource for member advocates, account executives, and other internal departments by providing guidance on pharmacy benefit policies, coverage criteria, and medication-related questions.

Clinical Program Development

- Assist in the development, implementation, and maintenance of prior authorization criteria, clinical guidelines, and utilization management programs using principles of evidence-based medicine.

- Support formulary management initiatives, including step therapy, quantity management, and other clinical programs designed to improve quality and control pharmacy costs.

- Evaluate emerging clinical literature and therapeutic guidelines to support ongoing updates to coverage criteria.

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