Utilization Management Pharmacist (Healthcare)

TL;DR

Utilization Management Pharmacist (Healthcare): Reviewing prior authorization requests and supporting clinical programs within a health tech environment with an accent on evidence-based decision making and regulatory compliance. Focus on optimizing medication use, ensuring adherence to URAC/NCQA standards, and providing clinical guidance to providers and members.

Location: Remote (Must be based in the US)

Salary: $125,000

Company

Enterprise health technology company providing comprehensive PBM and health benefit management solutions to rebuild trust in US healthcare.

What you will do

• Review prior authorization, appeals, and override requests using evidence-based clinical guidelines.
• Ensure compliance with federal and state regulations for Commercial, Exchange, Medicare, and Medicaid plans.
• Document clinical decisions according to URAC/NCQA utilization review standards.
• Provide professional and empathetic clinical support to members, prescribers, and pharmacies via phone.
• Stay current with clinical prescribing guidelines and regulatory changes to apply them to daily operations.
• Assist leadership with special projects, process improvements, and operational initiatives.

Requirements

• Active, unrestricted pharmacist license and a Bachelor’s or Doctor of Pharmacy degree.
• Minimum 2 years of pharmacy practice experience.
• 6 months to 1 year of experience with prior authorizations.
• Experience in managed care or pharmacy benefit management (PBM).
• Availability to work a rotating schedule including after hours, weekends, and holidays.
• Must be based in the United States to handle US-specific regulatory requirements.

Nice to have

• Call center experience.

Culture & Benefits

• Collaborative, fast-paced work environment focusing on service excellence.
• Patient-centered approach to clinical decision-making.
• Commitment to diversity, equity, and equal employment opportunities.