Description

Position: Senior Pharmacy Claims Analyst Location: Remote Duration: 3 Months Contract-to-Hire Potential About the Role: We are seeking a Senior Pharmacy Claims Analyst with deep, hands-on expertise in prior authorization (PA) and the end-to-end drug approval lifecycle. In this role you will own the analysis and adjudication review of pharmacy claims from the point of submission by covered entities through to final approval or denial, including the management of clinically appropriate drug substitutions and step-therapy pathways. This is a senior individual-contributor position for someone who knows formulary data inside and out, understands how coverage decisions are made, and can move confidently between the clinical, operational, and regulatory dimensions of pharmacy benefits. You will be a go-to subject-matter expert, helping resolve complex cases, surface trends, and improve the accuracy and speed of our approval process. Key Responsibilities: Prior Authorization & Drug Approval: Review, analyze, and adjudicate prior authorization requests against clinical criteria, plan design, and formulary rules, driving each case to a timely and well-documented approval or denial. Manage the full drug approval workflow—from initial submission by covered entities (including 340B and other covered entities) through clinical review, determination, and member/provider notification. Evaluate and apply step therapy, quantity limits, age/diagnosis edits, and medical-necessity criteria consistently and defensibly. Identify and recommend clinically appropriate drug substitutions (therapeutic interchange, generic/biosimilar substitution) in line with formulary tiers and coverage policy. Serve as an escalation point for complex, high-cost, or appealed cases, providing clear rationale that withstands clinical and regulatory scrutiny. Formulary & Claims Analysis: Maintain expert-level command of formulary data—tiers, NDC-level coverage, exclusions, preferred/non-preferred status, and rebate-relevant placements — and apply it accurately to claims and PA decisions. Analyze pharmacy claims data to detect adjudication errors, pricing discrepancies, utilization outliers, and potential fraud, waste, or abuse. Reconcile claims against plan design and reimbursement terms, investigating rejections and resolving root causes. Build and deliver reports and dashboards on PA volumes, turnaround times, approval/denial rates, and drug utilization trends. Compliance & Collaboration: Ensure all determinations comply with applicable federal and state regulations and accreditation standards (e.g., CMS, Medicare Part D, Medicaid, commercial plan requirements). Document decisions thoroughly to support audits, appeals, and regulatory review. Partner with pharmacists, clinical staff, network pharmacies, and benefit teams to clarify cases and refine criteria. Recommend process and policy improvements that increase accuracy, reduce turnaround time, and improve the provider and member experience. Required Qualifications: 5 years of experience in pharmacy claims, pharmacy benefits, or managed care, with a clear track record in prior authorization and drug approval. Expert knowledge of the end-to-end PA and drug approval process—from covered-entity submission through approval, denial, appeals, and substitution. Strong, demonstrated mastery of formulary data and structure (tiers, NDC codes, edits, exclusions, preferred status). Solid understanding of claims adjudication, pharmacy pricing concepts (e.g., AWP, MAC), rebates, and reimbursement. Working knowledge of regulatory and compliance requirements across Medicare, Medicaid, and commercial lines of business. Proficiency with data analysis tools—advanced Excel required; SQL and/or BI tools (Tableau, Power BI) strongly preferred. Excellent documentation, judgment, and communication skills, with the ability to justify determinations clearly. Certified Pharmacy Technician (CPhT), PharmD, RN, or equivalent clinical/managed-care background highly desirable. Preferred Qualifications: Experience with PBM or health-plan adjudication platforms and prior authorization systems. Familiarity with 340B and covered-entity program requirements. Experience supporting appeals, grievances, and audit readiness. Background contributing to formulary management or clinical criteria development.