Job Description

Key Responsibilities:

• Conduct prospective, concurrent, and retrospective utilization reviews for medications and pharmacy services in US insurance.
• Must have experience with Medical Part D.
• Apply clinical criteria (e.g., CMS guidelines, FDA labeling) to make coverage determinations.
• Review and process prior authorizations, step therapy, and quantity limit overrides.
• Collaborate with physicians, nurses, and customer service teams on clinical determinations.
• Document clinical decisions accurately within UR systems and according to regulatory requirements.
• Support appeals and grievance processes by reviewing denied claims and providing clinical input.
• Monitor and report utilization trends, potential fraud, waste, or abuse.
• Ensure compliance with federal and state regulations, NCQA/URAC standards, and plan policies.

Qualifications:

• Pharmacy College Graduate
• Active Pharmacist license
• 2–3 years of experience in managed care, clinical pharmacy, or utilization management.
• Strong knowledge of Medicare Part D, Medicaid formularies, and commercial insurance benefits.
• Familiarity with drug databases, claims systems, and prior authorization platforms.
• Excellent communication and critical thinking skills.

License/Certification

• Active Pharmacist license (Required)