Utilization Management Clinical Pharmacist

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

📋 Description

• Assess and determine the accuracy of prior authorization (PA) requests in alignment with established clinical criteria.

• Review and evaluate appeal requests for their clinical relevance and medical necessity.

• Utilize plan criteria, evidence-based guidelines (including comparative effectiveness data), and regulatory standards to provide timely decisions in a dynamic environment.

• Utilize clinical drug databases to meticulously examine drug data, indications, and clinical parameters during the adjudication process.

• Clearly and professionally communicate approval and denial decisions to providers and members, ensuring empathy in all interactions.

• Offer clinical support and advice to Pharmacy Support Specialists managing complex inquiries from prescribers, pharmacies, and members.

• Collaborate with prescribers and reach out to members to address medication issues, balancing compassionate care with operational responsibility.

• Assist in process improvement initiatives aimed at optimizing operational workflows, enhancing efficiency, and improving turnaround times.

⛳️ Requirements

• Doctor of Pharmacy (PharmD) degree from an accredited institution.

• Active and unrestricted pharmacist license in your state of residence.

• Previous experience in managed care, utilization management, or pharmacy benefit management (PBM) operations.

• Strong clinical expertise with the capability to critically assess and apply complex clinical data to individual case evaluations.

• Self-driven, highly organized, and able to work effectively both independently and as part of a team in a virtual setting.

• A keen attention to detail with a demonstrated ability to accurately follow and implement established plan criteria and protocols.

• Outstanding written and verbal communication skills, coupled with a strong customer-service orientation.

🏝️ Benefits

• Access to clinically appropriate and cost-effective medications.

• Adherence to stringent quality, regulatory, and turnaround standards.