Under the general supervision of the Assistant Director of Pharmacy, and according to standard procedure, a prior authorization pharmacist completes prior authorizations upon receiving orders from a licensed practitioner; performs all duties necessary to provide for the effective daily operation of all departmental services and programs; supervises support personnel in all work areas as assigned.

1. Review & Evaluate PA Requests

Analyze PA submissions from providers to ensure they meet clinical and formulary guidelines.

Review patient history, lab results, and diagnosis codes when available.

Assess medical necessity based on criteria such as FDA-approved indications, compendia, and internal policies.

2. Apply Clinical Criteria

Use evidence-based guidelines (e.g., Medicare Part D, NCCN, IDSA, ADA) to determine approval or denial.

Identify off-label use and evaluate its appropriateness.

3. Communicate with Providers

Request additional documentation or clarification when needed.

Explain coverage decisions and educate on formulary alternatives or step therapy requirements.

4. Document & Process Authorizations

Enter decisions into pharmacy benefit management (PBM) or health plan systems.

Ensure accurate record-keeping for compliance and audit purposes.

5. Collaborate with Internal Teams

Work with case managers, medical directors, and utilization review teams.

Participate in interdisciplinary discussions about complex or high-cost cases.

6. Monitor for Compliance & Fraud

Identify potential overuse, misuse, or inappropriate prescribing patterns.

Flag questionable cases for further investigation.

7. Maintain Up-to-Date Knowledge

Stay current on formularies, new drug approvals, clinical guidelines, and payer policies.

Attend continuing education and internal training sessions.

8. Support Appeals Process

Prepare clinical rationales for appeal responses.

Conduct Peer to Peer processes

Review new evidence submitted during appeal reviews.

9. Provide Education

Educate prescribers, patients, and internal staff about prior authorization processes and criteria.

Help reduce PA burden through proactive outreach and education on preferred alternatives.

10. Quality Assurance & Process Improvement

Participate in audits and contribute to quality improvement initiatives.

Help streamline workflows and improve efficiency in the PA process.

KNOWLEDGE AND SKILLS :

Please describe any specialized knowledge or skills, which are REQUIRED to perform the position duties.  Do not personalize the job description, credentials, or knowledge and skills based on the current associate.  List any special education required for this position.

 

EDUCATION: B.S in Pharmacy or PharmD

          

YEARS OF EXPERIENCE: One- or two-years hospital experience preferred.

          

REQUIRED SKILLS AND KNOWLEDGE: 

Demonstrated pharmacy practice skills required

Demonstrated written and verbal communication required

 

 

LICENSES & CERTIFICATIONS:  

Licensed or eligible for licensure in the State of Ohio