Pharmacist – Utilization Management (Managed Care)

About the role

This position reviews medication coverage requests for prior authorization and appeals. Using the Utilization Review system, the pharmacist evaluates clinical information against medical policy criteria and makes coverage determinations, sometimes conducting additional research beyond the policy.

Key responsibilities

• Make coverage determinations by evaluating physician requests for prior authorization or appeals against medical policy.
• Conduct prospective, concurrent, and retrospective utilization reviews for medications and pharmacy services in US insurance.
• Apply clinical criteria such as CMS guidelines and FDA labeling to make coverage decisions.
• 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 support appeals and grievance processes.

Required profile

• Pharmacy college graduate with an active pharmacist license.
• 1–3 years of experience in managed care, clinical pharmacy, or utilization management.
• Strong knowledge of Medicare Part D, Medicaid formularies, and commercial insurance benefits.

Required skills

• Familiarity with Medical Part D and CMS guidelines.
• Understanding of FDA labeling requirements.
• Experience with drug databases, claims systems, and prior authorization platforms.
• Proficiency in Utilization Review system for coverage determinations.