Pharmacy Prior Authorization Specialist for AI Evaluation

Evaluate and process complex prior authorization workflows for specialty medications while assessing and training AI tools that aim to automate pharmacy benefit management and specialty drug authorization. This role combines hands-on prior authorization casework with structured review and annotation of AI-generated recommendations to improve patient access to high-cost therapies.

• Process and manage prior authorization requests for specialty medications, biologics, and high-cost pharmaceuticals across commercial, Medicare Part D, and Medicaid payers.
• Review clinical documentation and pharmacy benefit criteria to determine medical necessity for specialty drug authorizations.
• Evaluate AI-generated pharmacy prior authorization recommendations for accuracy, completeness, and payer compliance.
• Coordinate with prescribers, specialty pharmacies, and payers to obtain timely medication authorizations.
• Manage appeals for denied pharmacy authorizations, 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 trends to identify opportunities for process improvement.
• Ensure compliance with payer-specific pharmacy benefit requirements and CMS Part D guidelines.
• Annotate AI outputs and provide structured feedback to support AI training datasets.

• Minimum 5 years of experience in pharmacy prior authorization, specialty medication access, or pharmacy benefit management.
• Deep knowledge of specialty drug formularies, step therapy protocols, and payer prior authorization criteria across commercial and government payers.
• Experience with specialty pharmacy platforms and pharmacy benefit management systems.
• Familiarity with Medicare Part D coverage determination and exception processes.
• Exceptional written and verbal English communication skills.
• High attention to detail, with the ability to evaluate clinical documentation and AI-generated outputs for accuracy and compliance.

• Certified Pharmacy Technician, CPhT, or Certified Prior Authorization Professional, CPAP credential.
• Experience with hub services and patient assistance programs for specialty medications.
• Background in specialty pharmacy, infusion services, or oncology or rheumatology drug access.
• Familiarity with AI tools and comfort evaluating AI-generated pharmacy content.
• Experience with manufacturer copay assistance and patient access programs.

• Location: Remote.
• Employment type: Hourly.

• $75.00 per hour.