Pharmacy Utilization Management Specialist

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

📋 Description

• Manage and process drug prior authorization cases received via fax, electronic prior authorization, phone, and email.

• Evaluate cases to ensure compliance with regulatory, accreditation, and turnaround-time standards.

• Record case notes for prior authorizations that necessitate review by a pharmacist or medical director.

• Execute test claims for authorizations that have been approved.

• Reach out to members and providers as required.

• Interact with providers through the department's phone queue and address their inquiries effectively.

• Conduct daily quality assurance checks to ensure compliance.

• Oversee the Pharmacy Utilization Management team email inbox.

• Handle electronic prior authorization requests.

• Propose process enhancements.

• Carry out other designated roles, responsibilities, and projects.

⛳️ Requirements

• Certified Pharmacy Technician (CPhT).

• High School Diploma or GED.

• Associate's degree in Healthcare, Nursing, or a related field, or equivalent experience.

• A minimum of 2 years of pharmacy experience.

• Preferred experience in a managed care/PBM environment.

• Familiarity with software/databases like RxClaims and PAHub preferred.

• Proficient in MS Office—Excel, Word, and PowerPoint preferred.

• Capable of prioritizing medical and pharmacy drug prior authorization requests in accordance with guidelines and turnaround times.

• Ability to accurately process a high volume of requests.

• Strong working knowledge of medical terminology.

• Capability to work both independently and collaboratively within a team.

• Ability to exercise sound judgment while adhering to rules and regulations.

• Comfortable working under standard office conditions and from home as needed.

• Willingness to work extended hours, including early mornings, evenings, weekends, or longer workdays as required.

• Flexibility in work schedule.

🏝️ Benefits

• Medical, dental, and vision coverage.

• Retirement plans.

• Paid time off.

• Employer-paid life and disability insurance, with options for additional buy-up coverage.

• Tuition assistance program.

• Well-being benefits.

• Comprehensive benefits package to support career advancement, individual and family health, and financial well-being.

• Eligibility for variable pay.