Job Description

Imagine360 is seeking a Clinical Pharmacist to join the team! The Clinical & Prior Authorization Pharmacist is responsible for evaluating medication prior authorization requests, ensuring appropriate utilization of pharmaceutical therapies, and supporting evidence-based clinical decision-making. This role collaborates with healthcare providers, care management teams, pharmacy operations, and health plan stakeholders to promote safe, effective, and cost-efficient medication use while ensuring compliance with regulatory requirements and organizational policies.

The pharmacist applies clinical knowledge, formulary guidelines, and utilization management criteria to review coverage determinations, appeals, and medication exceptions while maintaining high standards of customer service and quality.

Position Location: 100% remote

Duties/Responsibilities:

Prior Authorization Review

• Evaluate pharmacy and medical benefit prior authorization requests for appropriateness, safety, efficacy, and adherence to established clinical criteria.
• Apply formulary guidelines, utilization management programs, and evidence-based treatment recommendations to coverage determinations.
• Review specialty medication requests, step-therapy exceptions, quantity limits, and formulary exceptions.
• Make timely authorization decisions in accordance with regulatory and organizational turnaround requirements.
• Document clinical rationale and authorization outcomes accurately within utilization management systems.

Clinical Pharmacy Management

• Assess patient-specific clinical information, including diagnosis, laboratory values, medication history, and provider documentation.
• Ensure medication therapy aligns with current clinical guidelines, FDA-approved indications, and best practices.
• Identify opportunities to optimize therapy, enhance patient outcomes, and decrease clients and patients' cost
• Support formulary management initiatives and clinical program development.
• Participate in medication utilization reviews and quality improvement activities.

Provider & Member Support

• Collaborate with prescribers and clinical staff to obtain necessary clinical information for coverage determinations.
• Provide clinical recommendations and educational support regarding formulary alternatives and treatment options.
• Respond to provider inquiries regarding prior authorization requirements and coverage criteria.
• Communicate authorization decisions professionally and clearly.

Appeals & Grievances

• Review and evaluate pharmacy-related appeals, reconsiderations, and exception requests.
• Prepare clinical summaries and recommendations for appeal determinations.

Compliance & Quality

• Maintain compliance with applicable regulations, accreditation standards, and organizational policies.
• Support audits, quality assurance audits, and reporting activities.
• Participate in ongoing clinical and regulatory training programs.
• Contribute to process improvement initiatives that enhance efficiency and service quality.

Required Experience/Education:

• Doctor of Pharmacy (PharmD) or BS in Pharmacy degree from an accredited school of pharmacy required.

Licensure

• Active, unrestricted pharmacist license in good standing.
• Additional state licensure may be required based on business needs.

Experience

• 2-5 years of pharmacist experience in managed care, health plan, specialty pharmacy, hospital, ambulatory care, or prior authorization review.
• Experience reviewing pharmacy benefit and/or medical benefit prior authorizations preferred.
• Knowledge of utilization management principles and formulary management processes.

What can Imagine360 offer you?

• Multiple Health plan options
• Company paid employee premiums for disability and life insurance
• Parental Leave Policy
• 20 days PTO to start / 10 Paid Holidays
• Tuition reimbursement
• 401k Company contribution
• Company paid Short & Long term Disability plus Life Insurance
• Professional development initiatives / continuous learning opportunities
• Opportunities to participate in and support the company's diversity and inclusion initiatives

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Imagine360 is a health plan solution company that combines 50+ years of self-funding healthcare expertise. Over the years, we've helped thousands of employers save billions on healthcare. Our breakthrough total health plan solution is fixing today's one-size-fits-none PPO insurance problems with powerful, customized, member-focused solutions.

Imagine360 is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.

**RECRUITMENT AGENCIES PLEASE NOTE: Imagine360 will only accept applications from agencies/business partners that have been invited to work on a specific role. Candidate Resumes/CV's submitted without permission or directly to Hiring Managers will be considered unsolicited and no fee will be payable. Thank you for your cooperation**

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