PRN Pharmacist Reviewer – Medicare Part D Formulary Criteria Review

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🔥 4 minutes ago

🇺🇸 United States – Remote

⏱ Part Time

🟡 Mid-level

🟠 Senior

💊 Pharmacist

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📋 Description

• Review sponsor-submitted prior authorization and step therapy criteria for compliance with CMS Chapter 6 guidance during annual and monthly reviews • Evaluate PA criteria fields for consistency with FDA-approved labeling, recognized Part D compendia, and treatment guidelines • Evaluate step therapy criteria for clinical appropriateness, indication coverage, on-label/off-label standards, and burden of prerequisite therapy • Apply CMS principles for Part B versus Part D step therapy, indication-based formulary design, over-the-counter prerequisites, and formulary-file synchronization • Review utilization management for Medicare drugs selected for negotiation under the Inflation Reduction Act • Identify and evaluate more restrictive PA or ST requirements for selected drugs compared with formulary alternatives • Write clear, specific, and consistent comments to plan sponsors regarding failed criteria elements • Review resubmitted criteria, formulary files, and clinical justifications to determine whether concerns were resolved • Apply consistent pass/fail decisions and comments to identical criteria across formularies using identification codes and established precedents • Use drug information resources to evaluate the clinical basis of submitted criteria • Interpret and apply federal Medicare Part D statutes, regulations, and CMS guidance • Maintain current knowledge of CMS Part D policy, new drug approvals and indications, drug safety updates, and treatment-guideline changes • Meet fixed CMS review deadlines during annual and monthly review cycles

🎯 Requirements

• Doctor of Pharmacy degree from an accredited college or university • Current, active, unrestricted license to practice pharmacy in the United States • Minimum five years of experience in clinical pharmacy, formulary management, utilization management, pharmacy benefit management, or Medicare Part D • Experience developing or reviewing PA and ST criteria for a Part D plan sponsor, pharmacy benefit manager, or Pharmacy and Therapeutics (P&T) committee strongly preferred • Pharmacy residency or board certification preferred • Advanced knowledge of Medicare Part D coverage requirements and utilization management programs, including Chapter 6 of the Medicare Prescription Drug Benefit Manual • Strong understanding of FDA-approved versus medically accepted (compendia-supported) indications and coverage criteria • Strong clinical background with ability to review, interpret, and apply treatment guidelines and evidence-based literature • Proficiency in Micromedex DrugDex, AHFS Drug Information, NCCN Clinical Practice Guidelines, Clinical Pharmacology, Lexi-Drugs, and other drug information resources • Strong written communication skills, including concise, precise, grammatically correct findings for a regulatory audience • Ability to apply review criteria consistently and accurately across large volumes while meeting fixed deadlines • Strong analytical, critical thinking, problem-solving, and decision-making skills • Ability to work independently with minimal supervision while meeting productivity and quality expectations • Comfort working in structured databases and data-driven review tools such as Microsoft Access or SQL • Proficiency in Microsoft Office, including Teams, Word, Excel, Outlook, and SharePoint • Availability of approximately 20 hours per week during peak season expected • Estimated availability of 10–15 hours per month outside peak season

🏖️ Benefits

• Fully remote/work-from-home position • PRN seasonal work arrangement • Flexible workload outside peak season through a smaller monthly review cycle

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