About this role
Help improve AI systems that support pharmacy benefit management and specialty-drug authorization workflows. In this remote, hourly role, you will apply your expertise in formularies, step therapy, payer criteria, and specialty-medication access to evaluate AI-generated recommendations and strengthen patient access to critical therapies.
Key Responsibilities- Process and manage prior authorization requests for specialty medications, biologics, and high-cost drugs across commercial, Medicare Part D, and Medicaid plans.
- Review clinical documentation and pharmacy-benefit criteria to assess medical necessity for specialty-drug authorizations.
- Evaluate AI-generated prior authorization recommendations for accuracy, completeness, and compliance with payer requirements.
- Coordinate with prescribers, specialty pharmacies, and payers to secure timely medication authorizations.
- Manage denied-authorization appeals, including peer-to-peer requests and exception processes.
- Navigate payer formularies, step-therapy requirements, and specialty-drug coverage policies.
- Track authorization status, approval rates, and denial patterns to identify process-improvement opportunities.
- Maintain compliance with payer-specific pharmacy-benefit requirements and CMS Part D guidelines.
- Annotate AI outputs and provide structured feedback that supports AI training datasets.
- At least 5 years of experience in pharmacy prior authorization, specialty-medication access, or pharmacy benefit management.
- Strong knowledge of specialty-drug formularies, step-therapy protocols, and payer prior authorization criteria across commercial and government payers.
- Experience using specialty-pharmacy platforms and pharmacy benefit management systems.
- Familiarity with Medicare Part D coverage determinations and exception processes.
- Exceptional written and verbal English communication skills.
- Close attention to detail and the ability to assess clinical documentation and AI-generated outputs.
- Certified Pharmacy Technician or Certified Prior Authorization Professional credential.
- Experience with hub services and patient-assistance programs for specialty medications.
- Experience in specialty pharmacy, infusion services, or oncology or rheumatology drug access.
- Comfort using AI tools and reviewing AI-generated pharmacy content.
- Experience with manufacturer copay assistance and patient-access programs.
- Remote, hourly engagement.
- $75 per hour.
- Contribute to advanced healthcare AI workflows, collaborate with an AI research organization, and help shape technology used in healthcare revenue-cycle management and medication access.