Coverage Review Pharmacist

Who is Prescryptive? Prescryptive Health is a healthcare technology company delivering solutions that empower consumers. Prescryptive's secure, mobile-first products connect consumers, pharmacists, and employers, ultimately providing people with the information they need to make informed decisions and take control of their health. To learn more about Prescryptive Health, visit Prescryptive.com. About this roleThe Coverage Review Pharmacist plays a critical role in Prescryptive's pharmacy benefit management (PBM) operations by evaluating prior authorization (PA) requests and rendering final clinical determinations based on established criteria, evidence-based guidelines, and benefit design.This pharmacist ensures safe, appropriate, and cost-effective medication use while maintaining regulatory compliance and supporting member access. Reporting directly to the Sr. Manager, Coverage Review, this role partners closely with coverage review technicians, fellow pharmacists, and other clinical and operations teams. The Coverage Review Pharmacist also contributes to criteria development, quality review, and continuous improvement efforts, including collaboration on automation and AI model refinement that enhances workflow accuracy and efficiency.What you will doKey Accountabilities• Clinical Review and Determination - Evaluate and render final clinical decisions for medication prior authorization requests using evidence-based clinical criteria and benefit design requirements. • Quality and Compliance - Ensure determinations meet all regulatory, documentation, and internal quality standards, including HIPAA and URAC requirements. • Criteria Development and Optimization - Support creation, validation, and refinement of clinical criteria and coverage rules in alignment with current medical evidence and regulatory updates.• Collaboration & Process Improvement - Partner with the Coverage Review team and internal clinical and operations teams to enhance workflow quality, automation, and decision support tools. Position Responsibilities• Review and render clinical determinations for prior authorization requests per plan design, clinical criteria, and regulatory requirements. • Document determinations clearly, completely, and accurately in PA systems and PBM claims platforms. • Collaborate with coverage review technicians to ensure complete, timely, and accurate case processing.• Participate in quality audits, contributing to consistent application of clinical criteria. • Verify eligibility and benefit nuances as needed and consult provider offices to clarify clinical information supporting the determination. • Contribute to development, validation, and updates of coverage criteria and clinical content (e.g., integrating new evidence, guideline changes, benefit updates). • Collaborate with internal clinical, operations, and product/data teams on AI enabled workflow improvements and PA optimization to improve accuracy and turnaround time.• Support appeals or quality review processes where applicable (e.g., adverse determinations, case summaries for physician or medical director review). • Maintain up-to-date knowledge of therapeutic guidelines and drug information resources (e.g., Lexicomp, Micromedex, NCCN) to support evidence-based determinations. • Meet or exceed established performance metrics for clinical quality, accuracy, and turnaround time. Minimum Requirements• Doctor of Pharmacy (PharmD) degree from an accredited institution.• Active, unrestricted U.S. pharmacist license in good standing in at least one state. • 2 years of experience in prior authorization, utilization management, or clinical pharmacy review within a PBM, health plan, or managed care setting. • Strong understanding of PBM operations, and first hand experience with benefit design and coverage determination workflows. • Proficiency with prior authorization platforms and PBM claims systems, including documentation of determinations in real time. • Working knowledge of HIPAA, URAC-aligned documentation practices, and benefit design (commercial, Medicare Part D, Medicaid).• Demonstrated clinical judgment and ability to interpret and apply evidence-based criteria to complex cases. • Strong written and verbal communication skills and ability to collaborate effectively with team members across clinical and operational functions. • Ability to work independently in a remote, fast-paced, metric-driven environment (quality, volume, TAT). • Experience working in AI-enabled systems, automation tools, or machine learning-based decision support in a healthcare or PBM environment.• High attention to detail and accuracy in documentation and clinical analysis. Preferred Experience, in addition to minimum requirements• Experience contributing to criteria development or clinical content management within a PBM or payer setting. • Familiarity with Medicare Part D, Medicaid, and commercial coverage criteria. • Experience collaborating on AI model training or automation process improvement. • Board certification (e.g., BCPS, BCACP, BCGP) or equivalent managed care credential preferred.What we have to offer• The opportunity to grow alongside an early-stage company shaking up a big, old-fashioned industry• Flexible time off, including 12 paid holidays• 401k match plus 100% employer paid medical, dental, and vision premiums• Company contribution to Health Savings Account• Stock optionsPrescryptive is committed to fair pay practices. The projected annual salary for this position is $110K to $150K. When preparing an offer, we consider the candidates resume, experience, interview feedback, internal equity, and location.Prescryptive is an Equal Opportunity Employer. Prescryptive does not discriminate on the basis of race, religion, color, sex, gender identity, sexual orientation, age, non-disqualifying physical or mental disability, national origin, veteran status or any other basis covered by appropriate law. All employment is decided on the basis of qualifications, merit, and business need. Apply tot his job