We are looking for Pharmacy Prior Authorization & Specialty-Medication Access Specialist candidates for a project delivered through Mercor.
What you'll do
- Process and manage prior authorisation requests for speciality medications, biologics, and high-cost pharmaceuticals across commercial, Medicare Part D, and Medicaid payers.
- Review clinical documentation and pharmacy benefit criteria to determine medical necessity for speciality drug authorisations.
- Evaluate AI-generated pharmacy prior authorisation recommendations for accuracy, completeness, and payer compliance.
- Coordinate with prescribers, speciality pharmacies, and payers to obtain timely medication authorisations.
- Manage appeals for denied pharmacy authorisations, including peer-to-peer requests and exception processes.
- Navigate payer formularies, step therapy requirements, and speciality drug coverage policies.
- Track authorisation status, approval rates, and denial trends to identify process improvement opportunities.
- Ensure compliance with payer-specific pharmacy benefit requirements and CMS Part D guidelines.
- Annotate AI outputs and provide structured feedback to support AI training datasets.
What you need
- 5+ years of experience in pharmacy prior authorisation, speciality medication access, or pharmacy benefit management.
- Deep knowledge of speciality drug formularies, step therapy protocols, and payer PA criteria across commercial and government payers.
- Experience with speciality pharmacy platforms and pharmacy benefit management (PBM) systems.
- Familiarity with Medicare Part D coverage determination and exception processes.
- Exceptional written and verbal English communication skills.
- High attention to detail with the ability to evaluate clinical documentation and AI-generated outputs.
Nice to have
- Certified Pharmacy Technician (CPhT) or Certified Prior Authorisation Professional (CPAP) credential.
- Experience with hub services and patient assistance programs for speciality medications.
- Background in speciality pharmacy, infusion services, or oncology/rheumatology drug access.
- Familiarity with AI tools and comfort evaluating AI-generated pharmacy content.
- Experience with manufacturer copay assistance and patient access programs.
Expertise
pharmacy prior authorisationspeciality medication accesspharmacy benefit managementdrug formulariesstep therapypayer PA criteriaspeciality drug formulariesstep therapy protocolsspeciality pharmacy platformspharmacy benefit management (PBM) systemsMedicare Part D coverage determinationpayer formularies
Who you work with
Project and contracting process: Mercor. Applications continue on the provider's website.