Utilization Management Pharmacist – Temp, Temp-to-hire

🕒 May 12

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Capital Rx

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 2017

⚕️ Healthcare Insurance

💳 Fintech

🤖 Artificial Intelligence

Healthcare Insurance • Fintech • Artificial Intelligence

Capital Rx is the fastest growing healthtech company in America, dedicated to transforming the prescription pricing and patient care landscape. Founded in 2017, it offers innovative pharmacy benefit management (PBM) services, including customizable pharmacy benefits for large employers and an AI-powered care navigation platform. Capital Rx focuses on delivering cost-effective solutions and operational efficiencies to clients while ensuring transparency and quality care for patients.

📋 Description

• Review and make timely, evidence-based decisions on prior authorizations, appeals, and override requests using clinical guidelines and benefit criteria. • Ensure compliance with federal, state, and internal regulations across Commercial, Exchange, Medicare, and Medicaid plans. • Accurately document clinical decisions and maintain thorough records in accordance with regulatory and accreditation (URAC/NCQA) utilization review standards. • Provide clear, empathetic support to members, prescribers, and pharmacies by responding to clinical inquiries via phone, demonstrating professionalism, active listening, and a patient-centered approach. • Stay current with clinical prescribing guidelines, internal policies, and regulatory changes, and apply them to daily responsibilities. • Follow all internal procedures, job aids, and HIPAA guidelines to protect patient privacy and data security. • Identify and report potential fraud, waste, and abuse. • Support training and development of new and existing team members as needed. • Assist leadership with special projects, process improvements, and operational initiatives

🎯 Requirements

• Minimum of 6 months to a year of prior authorization experience • Active, unrestricted, pharmacist license • Bachelor’s or Doctor of Pharmacy degree • Minimum of 2 years of pharmacy practice experience • Experience in managed care or pharmacy benefit management (PBM) • Strong communication, writing, and organizational skills • Ability to manage multiple priorities in a high-volume, metric-driven environment • Availability to work after hours, weekends, and holidays on a rotating schedule