Utilization Management Clinical Pharmacist
Remote
Job Summary
Evaluate and adjudicate prior authorization and appeal requests for accuracy against established clinical criteria, applying plan standards, evidence-based guidelines, and comparative effectiveness research to ensure timely, cost-effective determinations. Leverage clinical drug databases to review indications and parameters while communicating approval and denial decisions clearly to providers and members. Provide clinical support to Pharmacy Support Specialists, collaborate with prescribers to resolve medication concerns, and support process improvement initiatives to optimize turnaround times and operational workflows. Maintain up-to-date knowledge of managed care trends and utilization management workflows within a fast-paced, virtual environment.
Required Qualifications
- Experienced managed care pharmacists
- Apply data-driven insights and evidence-based guidelines to clinically-based determinations of coverage
- Utilize comparative effectiveness research according to the TruDataRx Clinical Process
- Maintain compliance with strict quality, regulatory, and turnaround standards
- Evaluate and adjudicate prior authorization (PA) requests for accuracy and against established clinical criteria
- Evaluate and adjudicate appeal requests for clinical appropriateness and medical necessity
- Apply plan criteria, evidence-based guidelines (including comparative effectiveness data), and regulatory standards to deliver timely determinations
- Leverage clinical drug databases to accurately review drug data, indications, and clinical parameters during the adjudication process
- Communicate approval and denial decisions clearly, professionally, and empathetically to providers and members
- Provide clinical support and guidance to Pharmacy Support Specialists handling complex inquiries from prescribers, pharmacies, and members
- Collaborate with prescribers and outreach to members to resolve medication concerns, balancing compassionate care with operational accountability
- Support process improvement initiatives to streamline operational workflows, boost efficiency, and optimize turnaround times
- Maintain up-to-date knowledge of relevant managed care trends, comparative effectiveness research, clinical guidelines, and utilization management workflows
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