Insurance Pharmacy Claims Analyst | Remote

Role Overview

Apply your pharmacy prior authorization expertise to evaluate medication access workflows, payer criteria, and specialty drug approval processes within advanced healthcare systems.

What You Will Be Doing

• Review and process prior authorization requests for specialty, biologic, and high-cost medications across multiple payer types
• Evaluate AI-generated authorization recommendations for accuracy, completeness, and compliance with payer rules
• Interpret formulary requirements, step therapy protocols, and medical necessity criteria
• Coordinate with prescribers, pharmacies, and payers to support timely medication access
• Manage appeals, exception requests, and peer-to-peer authorization workflows
• Monitor authorization trends including approval rates, denials, and bottlenecks
• Ensure adherence to CMS Part D and payer-specific pharmacy benefit regulations
• Provide structured feedback on AI outputs to improve automation quality

Who You Are Looking For

• Experienced professional in pharmacy prior authorization or specialty medication access
• Strong understanding of PBM systems, payer formularies, and specialty drug workflows
• Familiarity with Medicare Part D, Medicaid, and commercial payer authorization processes
• Experience working with specialty pharmacy or drug access programs
• Strong communication skills and ability to interpret clinical and payer documentation
• Detail-oriented professional comfortable evaluating structured workflows and decisions

Role Details

• Compensation: $75 per hour
• Work style: Fully remote, flexible independent contract
• Duration: Ongoing project-based engagement