Insurance Pharmacy Claims Analyst

Role overview

This contract opportunity is for a pharmacy prior authorization specialist who can review medication access requests and assess them against payer requirements, formulary rules, and specialty drug approval criteria within a healthcare workflow.

Core responsibilities

• Examine and adjudicate prior authorization submissions for specialty, biologic, and other high-cost medications across different payer plans.
• Check AI-assisted authorization suggestions for correctness, completeness, and alignment with insurer guidelines.
• Read and apply formulary provisions, step therapy rules, and medical necessity standards.
• Work with prescribing clinicians, pharmacies, and payers to help avoid delays in medication access.
• Handle appeals, exemption requests, and peer-to-peer review processes tied to prior authorization decisions.
• Track trends in approvals, denials, and workflow slowdowns to identify problem areas.
• Maintain compliance with CMS Part D requirements and payer-specific pharmacy benefit policies.
• Share structured feedback on AI-generated outputs to help refine automation quality.

Candidate profile

The ideal professional has hands-on experience in pharmacy prior authorization or specialty medication access and understands PBM workflows, payer formularies, and specialty drug distribution processes. Familiarity with Medicare Part D, Medicaid, and commercial plan authorization procedures is important, along with experience in specialty pharmacy or medication access support programs. The role also calls for strong written and verbal communication skills, the ability to interpret clinical and payer documents, and a detail-focused approach to reviewing structured cases and decisions.

Compensation and work arrangement

This is a fully remote, flexible independent contract assignment with pay set at $75 per hour. The work is ongoing and project-based.

Application notes

Shortlisted candidates will be contacted with the next steps in the process.