PBM Utilization Management Pharmacist

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

📋 Description

• Evaluate and make prompt, evidence-based decisions on prior authorizations, appeals, and override requests utilizing clinical guidelines and benefit criteria.

• Ensure adherence to federal, state, and internal regulations across Commercial, Exchange, Medicare, and Medicaid plans.

• Precisely document clinical decisions and uphold comprehensive records in accordance with URAC/NCQA utilization review standards.

• Offer assistance to members, prescribers, and pharmacies by addressing clinical inquiries via phone.

• Implement current clinical prescribing guidelines, internal policies, and updates in regulations.

• Adhere to internal procedures, job aids, and HIPAA regulations to safeguard patient privacy and data security.

• Detect and report potential fraud, waste, and abuse.

• Aid in the training and development of team members.

• Support leadership with special projects, process enhancements, and operational initiatives.

⛳️ Requirements

• Active, unrestricted pharmacist license.

• Bachelor’s or Doctor of Pharmacy degree.

• At least 2 years of experience in pharmacy practice.

• Excellent communication, writing, and organizational abilities.

• Capability to manage multiple priorities in a fast-paced, metric-driven environment.

• Willingness to work after hours, weekends, and holidays on a rotating basis.

• Call center experience is preferred.

• A minimum of 6 months of prior authorization or utilization management experience is preferred.

• Experience in managed care or pharmacy benefit management (PBM) is preferred.

🏝️ Benefits

• Comprehensive health, dental, and vision insurance.

• Competitive salary and performance-based bonuses.

• Opportunities for professional development and continuing education.

• Flexible work schedules and remote work options.

• Generous paid time off and holiday leave.