Clinical Pharmacy Reviewer (Pharmacist) - Remote

About this role

The Clinical Pharmacy Reviewer (Pharmacist) evaluates complex prior authorization requests, appeals, and medication coverage determinations to ensure clinical appropriateness and compliance with evidence-based guidelines. Acting as a subject matter expert in pharmacy benefit management, this role interprets complex drug criteria, formulary guidelines, step therapy, and quantity limits for specialty and non-specialty medications. Through rigorous Drug Utilization Review (DUR) and objective decision-making, the Clinical Pharmacy Reviewer upholds medical necessity standards, directly impacting Dane Street's commitment to high-quality healthcare delivery and regulatory excellence.

At Dane Street, we believe exceptional employee experiences create exceptional client experiences. Our culture is built on collaboration, continuous improvement, accountability, and care.

We care for our customers, we care for our employees, and we care for one another. Every team member plays an important role in creating an environment where people feel respected, supported, empowered to grow, and inspired to do meaningful work.

Job Responsibilities: Core Responsibilities

Perform clinical evaluations for complex Prior Authorization (PA) requests, appeals, step therapy exceptions, and quantity limit overrides across various lines of business.

Interpret and apply clinical practice guidelines, Drug Utilization Review (DUR) principles, and formulary specifications to ensure safe and evidence-based medication coverage decisions.

Analyze clinical documentation, medical records, diagnostic findings, and treatment histories, specifically for specialty and high-cost medications.

Customer/Client Support

Provide expert consultation and rationale to clients, health plans, Pharmacy Benefit Managers (PBMs), and medical directors regarding complex pharmacy determinations.

Deliver clear, well-reasoned written and verbal communication regarding appeal decisions and clinical policy interpretations.

Collaboration

Work alongside peer pharmacists, medical reviewers, and pharmacy operations staff to streamline review turnarounds and ensure clinical consistency.

Participate in clinical policy updates, committee review preparations, and cross-functional quality assurance checks.

Compliance

Ensure all clinical decisions and documentation comply with Medicare Part D, Medicaid, commercial benefit rules, HIPAA, and client Service Level Agreements (SLAs).

Maintain strict adherence to regulatory determination timelines, clinical compliance mandates, and accredited organizational standards.
Qualifications: EDUCATION/CREDENTIALS:

Doctor of Pharmacy (PharmD) degree from an accredited university.

Active, unencumbered pharmacist license in any U.S. State.

Must Haves:

Minimum of 3 years of Prior Authorization and/or Appeals review experience within a PBM environment.

Preferred Qualifications:

Experience with Medicare Part D and Medicaid pharmacy benefits.

Knowledge of commercial insurance pharmacy benefits and formulary management strategies.

Knowledge of step therapy requirements, quantity limit programs, and specialty medications.

In-depth knowledge of Drug Utilization Review (DUR).

Demonstrated ability to interpret and apply complex clinical guidelines.

Required skills

• HIPAA Compliance
• Customer Service