Senior Manager, Coverage Review Pharmacist

Job not on LinkedIn

November 13

🌴 South Carolina – Remote

Although this job is listed in South Carolina, this company may be open to hiring remote in other states.

🗿 South Dakota – Remote

Although this job is listed in South Dakota, this company may be open to hiring remote in other states.

+2 more states

🌴 South Carolina – Remote 🗿 South Dakota – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote

💵 $135k - $165k / year

⏰ Full Time

🟠 Senior

👔 Manager

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Prescryptive Health, Inc.

WebsiteLinkedInAll Job Openings

Healthcare Insurance • SaaS • B2B

Prescryptive Health, Inc. is a healthcare technology company that operates the myPrescryptive platform to help patients, pharmacies, employers, health systems, and pharma manufacturers manage and optimize prescription medications. Its SaaS platform provides real-time patient alerts, digital prescription management (no app required), EHR integration, and AI-driven pricing tools to improve medication adherence, transparency, affordability, and pharmacy profitability. Prescryptive offers employer-facing benefit solutions (emPBM), pharmacy pricing optimization, and consumer-facing tools to compare prices and track medication spend, with security certifications such as HITRUST.

201 - 500 employees

Founded 2017

⚕️ Healthcare Insurance

☁️ SaaS

🤝 B2B

📋 Description

• Lead the Prior Authorization and Coverage Review function, ensuring clinical accuracy, operational compliance, and timely determinations. • Manage and develop a team of pharmacists and pharmacy technicians, fostering clarity, ownership, and continuous improvement. • Maintain operational excellence through standardized SOPs, QA programs, and documentation standards aligned industry standards and internal requirements. • Use AI and automation to enhance case triage, improve turnaround time, and strengthen decision quality. • Partner cross-functionally with Clinical Operations, Compliance, and Technology to evolve criteria, optimize workflows, and advance the member experience. • Ensure all prior authorization and coverage determinations meet turnaround time requirements and Prescryptive’s internal quality standards. • Review and approve complex or escalated prior authorization requests, providing clinical input on appeals and high-impact cases. • Monitor service levels, documentation accuracy, and technician performance, making staffing or process adjustments as needed.

🎯 Requirements

• Doctor of Pharmacy (PharmD) required; active, unrestricted pharmacist license in good standing. • 5+ years of clinical or PBM experience with demonstrated experience in prior authorization or coverage review. • Proven ability to lead and coach clinical and technical staff in a performance-driven, quality-focused environment. • Strong understanding of URAC or ERISA requirements, clinical policy criteria, and evidence-based decision-making. • Experience developing, implementing, and maintaining SOPs, QA programs, and audit processes. • Demonstrated proficiency with AI decision-support or automation tools for clinical case management. • Ability to balance member-first advocacy with regulatory adherence and benefit accuracy. • Exceptional written and verbal communication skills; able to convey clinical determinations clearly to providers, members, and internal partners. • Strong collaboration skills and comfort operating in a fast-paced, evolving organization.

🏖️ Benefits

• Flexible time off, including 12 paid holidays • 401k match plus 100% employer paid medical, dental, and vision premiums • Company contribution to Health Savings Account • Stock options