Utilization Management Clinical Pharmacist II

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

📋 Description

• Assess, investigate, and resolve first- and second-level clinical appeals as well as intricate drug coverage requests according to established plan criteria and evidence-based clinical guidelines.

• Leverage extensive comparative effectiveness data, medical literature, and patient-specific charts to establish medical necessity for non-formulary or specialized therapies.

• Complete appeal resolutions within stringent regulatory, client-specific, and accreditation compliance timelines.

• Conduct professional Peer-to-Peer telephonic reviews directly with prescribing physicians and advanced practice providers.

• Discuss reasons for denials, clinical alternatives, and documentation requirements.

• Manage escalated, sensitive, or emotionally charged telephone inquiries from members and providers.

• Maintain a balance between clinical policy adherence and a customer-service-oriented approach.

• Record verbal conversations, clinical rationales, and final appeal resolutions in the internal utilization management platform.

• Act as a subject matter expert and escalation resource for Clinical Pharmacist I and Pharmacy Support Specialist teams.

• Identify patterns in clinical appeals and provider objections.

• Offer structured feedback to clinical leadership aimed at optimizing formulary design and criteria documentation.

• Perform additional duties as assigned.

⛳️ Requirements

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

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

• A minimum of 1–2 years of direct experience in managed care, utilization management, or pharmacy benefit management (PBM) operations, with a strong preference for candidates with experience in clinical appeals.

• Outstanding verbal communication and active listening abilities.

• Proven capability to navigate complex clinical phone discussions confidently and professionally with both physicians and concerned members.

• Advanced analytical skills to thoroughly evaluate complex medical literature and chart notes.

• Ability to convert technical clinical parameters into clear, logical, and defensible rationales.

• Highly organized, self-driven, and adept at managing complex caseloads independently within a virtual team setting.

• Familiarity with high-cost specialty medication classes, oncology pipelines, or rare disease therapeutics.

• Direct experience with specialized PBM processing architectures, external portal frameworks, and clinical drug databases (e.g., Medi-Span, First Databank).

• Extensive knowledge of URAC, NCQA, and CMS appeal compliance standards.

• Ability to collaborate effectively with colleagues in a team environment.

• Capacity to achieve results using resources that are not under your direct control.

• Openness to acknowledge when assistance is needed and the willingness to seek help.

• A continual drive for curiosity and problem-solving.

• A desire for ongoing learning and personal growth.

🏝️ Benefits

• Comprehensive health benefits, including medical, dental, and vision coverage.

• Competitive salary with performance-based bonuses.

• Opportunities for professional development and continuous education.

• Flexible work environment with options for remote work.

• Generous paid time off and holiday policies.