Clinical Utilization Management Pharmacist

This is a fully remote position, open to applicants in United States.

📋 Description

• Act as the clinical authority for specialty medications across both pharmacy and medical benefits.

• Engage with physicians, nurses, pharmacists, members, clients, and consultants concerning high-cost cases, dose management, genetic testing, therapeutic substitutions, and specialty drug cost management.

• Oversee prior authorization processes, high-cost cases, claims editing, and the development of clinical policies.

• Carry out outreach for prior authorization to prescribers to gather clinical information, clarify requests, and facilitate prompt case resolutions.

• Correspond with prescribers and clinical stakeholders via phone, email, or fax regarding prior authorization requests, clinical documentation, and benefit prerequisites.

• Articulate utilization management criteria, coverage decisions, and suitable therapeutic alternatives through evidence-based clinical discussions.

• Offer prior authorization guidance, clinical context, and support for member-facing team members.

• Directly communicate with members as necessary about prior authorization inquiries and clinical or coverage-related details.

• Design clinical programs for managing medical and pharmacy benefits.

• Define, document, and deliver outcomes for plan sponsors.

• Assess and summarize clinical literature along with the financial implications of medication management options.

• Present clinical and cost-effectiveness information as a subject matter expert.

• Execute additional duties as assigned.

⛳️ Requirements

• A Bachelor’s degree in Pharmacy or a PharmD degree is mandatory.

• Must hold a current, unrestricted license as a Registered Pharmacist in the state of residence, or have the ability to obtain reciprocity within 4 months, depending on state laws or client contracts.

• Other State Pharmacy Licenses may be necessary based on business requirements.

• Board of Pharmacy Certification is preferred in Pharmacotherapy, Ambulatory Care, or Oncology Care.

• Required pharmacy experience in retail, hospital, managed care, or other pharmacy-related environments.

• Essential experience and knowledge in Pharmacy and Medical specialty benefits.

• Proficiency in Microsoft Excel, PowerPoint, and Word is required.

• Experience with clinical communication directed towards physicians is preferred.

• Participate in, comply with, and support compliance program objectives.

• Ability to consistently interact cooperatively and respectfully with colleagues.

• Work schedule: Monday to Friday, 8am to 5pm.

🏝️ Benefits

• Comprehensive industry-leading benefits for Health, Dental, and Vision insurance.

• 20 days of paid time off.

• 4 weeks of paid parental leave.

• 9 paid holidays.

• 401K company match of up to 5% with no vesting requirement.

• Adoption Assistance Program.

• Flexible Spending Account.

• Educational Assistance Plan and support for Professional Memberships.

• Referral Bonus Program offering up to $750!