Pharmacy Utilization Management Specialist

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

📋 Description

• Establish and handle drug prior authorization requests received via fax, ePA, phone, and email.

• Conduct comprehensive case reviews to ensure compliance with regulatory, accreditation, and turnaround-time standards.

• Record pertinent case notes for prior authorizations that necessitate pharmacist or medical director evaluation.

• Execute test claims for authorizations that have been approved.

• Reach out to members and providers as needed.

• Interact with providers through the department phone queue and address provider inquiries effectively.

• Perform daily quality assurance checks for compliance purposes.

• Oversee the Pharmacy UM team email inbox.

• Manage electronic requests for prior authorization.

• Propose process enhancements.

• Undertake other assigned roles, responsibilities, and projects.

⛳️ Requirements

• Certified Pharmacy Technician (CPhT) credential is required.

• A High School Diploma or GED is mandatory.

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

• A minimum of 2 years of pharmacy experience is essential.

• Experience in a managed care/PBM setting is preferred.

• Familiarity with software/database systems such as RxClaims and PAHub is advantageous.

• Proficiency in MS Office applications—Excel, Word, and PowerPoint is preferred.

• Capability to prioritize medical and pharmacy drug PA requests in accordance with guidelines and turnaround times.

• Competence in processing a high volume of requests accurately.

• Basic understanding of medical terminology is required.

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

• Capacity to exercise appropriate judgment while adhering to rules and regulations.

• Must be able to function under standard office conditions and work from home when necessary.

• Must be able to simultaneously use a telephone/headset and PC/keyboard, and remain seated for prolonged periods.

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

🏝️ Benefits

• Medical, dental, and vision insurance.

• Retirement savings plans.

• Paid time off for personal use.

• Employer-funded life and disability insurance, with opportunities for additional coverage.

• Tuition assistance program.

• Well-being initiatives.

• Comprehensive benefits package designed to promote career growth, individual and family health, and financial well-being.

• Eligibility for variable pay options.