ESSENTIAL RESPONSIBILITIES
- Make coverage determinations by evaluating physician requests for prior authorization or appeals against medical policy through the Utilization Review system. Update the system records appropriately to ensure claims are properly routed and paid.
- Conduct research beyond medical policy review to make decisions on medication coverage requests.
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
- 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.
- Familiarity with drug databases, claims systems, and prior authorization platforms.
- Excellent communication and critical thinking skills.
License/Certification
- Required: Active Pharmacist license
