Clinical Pharmacist – Utilization Review | Hybrid
Position Summary:
The Clinical Pharmacist – Utilization Review is responsible for conducting clinical reviews of medication requests to determine medical necessity, appropriateness, and compliance with plan guidelines. Working closely with medical directors, case managers, and providers, this role ensures safe, cost-effective, and evidence-based pharmaceutical care for members.
Key Responsibilities:
- Conduct prospective, concurrent, and retrospective utilization reviews for medications and pharmacy services in US insurance.
- Must have experience with InterQual, MCG tools
- Apply clinical criteria (e.g., CMS guidelines, FDA labeling, InterQual, MCG) 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.
Job Type: Full-time
Benefits
- Work from home
Application Question(s)
- Previous Salary?
- Expected Salary?
Experience
- Medicare Part D: 2 years (Preferred)
- Medicaid formularies: 2 years (Preferred)
- BPO Insurance benefits: 2 years (Preferred)
- BPO Claims/prior authorization : 2 years (Preferred)
- MCG Tools : 2 years (Required)
- InterQual Tool: 2 years (Required)
License/Certification
- Active Pharmacist license (Required)
Work Location: Hybrid remote in Taguig
