Pharmacy Prior Authorization & Specialty-Medication Access Specialist

$75/hr

50 people hired

RemoteUSTechnology5-8 YearsContractPosted Aug 13, 2026

About this role

You will support the evaluation and improvement of AI systems designed to automate pharmacy prior authorization, specialty-medication access, and pharmacy benefit workflows. The role requires strong knowledge of specialty drug formularies, step therapy requirements, payer authorization criteria, Medicare Part D, Medicaid, and commercial pharmacy benefits. You will review AI-generated prior authorization recommendations, identify clinical or payer-policy inaccuracies, manage complex specialty medication access scenarios, and provide structured expert feedback to improve healthcare AI systems.

Responsibilities

Pharmacy prior authorization: Process and manage authorization requests for specialty medications, biologics, and high-cost pharmaceuticals across commercial, Medicare Part D, and Medicaid payers.
Clinical documentation review: Assess clinical records and pharmacy benefit criteria to determine medical necessity and authorization eligibility.
AI output evaluation: Review AI-generated pharmacy prior authorization recommendations for accuracy, completeness, and payer compliance.
Medication access coordination: Work with prescribers, specialty pharmacies, and payers to obtain timely medication approvals.
Appeals management: Support denied pharmacy authorization appeals, peer-to-peer requests, coverage exceptions, and escalation processes.
Formulary management: Navigate payer formularies, specialty drug coverage policies, step therapy requirements, and prior authorization criteria.

Qualifications

Minimum 5+ years of professional experience in pharmacy prior authorization, specialty medication access, pharmacy benefit management, or a closely related field.
Deep knowledge of specialty drug formularies, step therapy protocols, and payer prior authorization criteria across commercial and government payers.
Experience working with specialty pharmacy platforms and Pharmacy Benefit Management (PBM) systems.
Strong familiarity with Medicare Part D coverage determinations, authorization requirements, and exception processes.
Experience reviewing clinical documentation for specialty-drug medical necessity and payer coverage requirements.
Ability to identify discrepancies in authorization requests, coverage policies, and AI-generated pharmacy recommendations.
Exceptional written and verbal English communication skills.
High attention to detail and ability to independently evaluate complex pharmacy and medication-access workflows.
Must be based in the United States.