Senior Remote Prior Authorization

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.

This is a critical, high-trust role for a "PRO" who can independently manage our entire prior authorization and appeals process from end to end with minimal supervision. We need a problem-solver who can navigate the complexities of the US insurance system to ensure our patients get their medications without delay.

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 (chart notes, lab results, therapy failure history) to build a strong case for approval.

• Denial & Appeal Management: Aggressively follow up on all pending requests. When a PA is denied, you will analyze complex denial codes (e.g., CO 50, PR 23) , 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 (e.g., CoverMyMeds, Surescripts) and directly through PBM portals (e.g., CVS Caremark, Express Scripts, OptumRx).

• Stakeholder Communication: Serve as the primary liaison between our pharmacy, US-based insurance companies, and prescribers' offices. You must be able to argue persuasively and prepare 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)

• Experience: 3-5+ years of direct, hands-on experience in prior authorization, specifically for a U.S.-based pharmacy or healthcare provider.

• U.S. Healthcare Knowledge: Expert-level understanding of the US healthcare system, including PBMs, Medicare Part D, and Medicaid.

• Appeals Expertise: A proven track record of successfully managing and overturning complex denials, including "Step Therapy" and "Medical Necessity" appeals.

• Communication Skills: Exceptional (C1/C2 Level) English verbal and written communication. Must be confident, persuasive, and professional in negotiations with insurance agents and clinical staff.

• Technical Skills: Proficiency with EMR/EHR systems and e-authorization platforms like CoverMyMeds or Surescripts.

• Work Ethic: Highly organized, self-motivated, and detail-oriented. Must have a proven ability to work independently in a remote EST-based schedule.

• Exclusivity: Ability to commit to a full-time, exclusive role dedicated solely to Simplex Pharmacy.

• Remote Setup: A quiet, private home office with high-speed, reliable internet and a backup power solution (UPS/generator) to ensure 100% uptime during work hours.

Preferred Qualifications:

• Certified Pharmacy Technician (CPhT) certification.

• Direct experience with US retail pharmacy dispensing software (e.g., PioneerRx, Rx30, ScriptPro).

What We Offer:

• A highly competitive, premium market salary (in PKR) commensurate with your expert-level experience.

• A stable, full-time, and long-term remote position.

• An autonomous role where you will be a critical, trusted member of our core team, making a direct impact on patient care.

How to Apply:

Please send:

1) CV

2) short Cover Note (1-2 lines stating your US payer experience)

3) Best time for an interview (EST).

Email to: or apply via LinkedIn.

Or you can WhatsApp the details