Senior Remote Prior Authorization & Clinical Appeals Specialist (US Pharmacy)

Senior Remote Prior Authorization & Clinical Appeals Specialist (US Pharmacy)

Job Title : Senior Remote Prior Authorization & Clinical Appeals Specialist (US Pharmacy)

Company : Simplex Pharmacy

Location : Remote (Pakistan-Based)

Work Schedule : Full‑Time, 9 : 00 AM – 5 : 00 PM EST (Monday – Friday)

About Simplex Pharmacy :

Simplex Pharmacy is a busy, independent pharmacy in Brooklyn, NY, dedicated to exceptional patient care. Our leadership team is looking for a top‑tier, expert‑level Prior Authorization Specialist to join us as an exclusive, full‑time remote partner.

Key Responsibilities :

• End‑to‑End PA Management : Independently manage the complete PA workflow for all prescriptions, specializing in high‑cost, specialty, and non‑formulary medications.
• Benefits Investigation : Conduct meticulous verification of patient insurance eligibility, benefits, co‑pays, and deductible status.
• Clinical Review & Submission : Collaborate with prescribers’ offices to gather necessary clinical documentation to build a strong case for approval.
• Denial & Appeal Management : Aggressively follow up on all pending requests. When a PA is denied, analyze complex denial codes, immediately initiate the appeals process, and manage multi‑level appeals, including Medicare Part D Redeterminations and Reconsiderations.
• System & Platform Proficiency : Accurately submit and track requests using ePA platforms (CoverMyMeds, Surescripts) and directly through PBM portals (CVS Caremark, Express Scripts, OptumRx).
• Stakeholder Communication : Serve as the primary liaison between our pharmacy, US‑based insurance companies, and prescribers’ offices, preparing documentation for peer‑to‑peer review calls.
• Documentation : Maintain meticulous, HIPAA‑compliant records of all requests, communications, denials, and approvals within our pharmacy’s EHR / EMR system.

Must‑Have Qualifications (Non‑Negotiable)

Preferred Qualifications :

What We Offer :

How to Apply :

Please send : CV; best time for an interview (EST) to or apply via LinkedIn. You may also WhatsApp the details at .

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