Utilization Management Clinical Pharmacist II

Job not on LinkedIn

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $140k / year

⏰ Full Time

🟢 Junior

💊 Pharmacist

👻 Ghost score 10%

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Career Opportunities International

WebsiteLinkedInAll Job Openings

11 - 50 employees

💼 Consulting

🎯 Recruiter

👥 HR Tech

Consulting • Recruitment • HR Tech

Career Opportunities International is a global executive search firm specializing in sourcing, recruiting, and strategic partnerships. The company focuses on connecting top-tier corporate leaders with leading organizations worldwide. Established in May 1998, C. O. I Executives leverages its dedicated, diverse research team to ensure high-caliber talent meets the right companies. With advanced tools and over 25 years of experience, Career Opportunities International delivers highly qualified candidates efficiently, facilitating sustainable partnerships between stakeholders.

📋 Description

• Evaluate, research, and adjudicate first- and second-level clinical appeals and highly complex drug coverage requests against established plan criteria and evidence-based clinical guidelines • Utilize comprehensive comparative effectiveness data, medical literature, and patient-specific charts to determine medical necessity for non-formulary or specialized therapies • Complete appeal determinations within strict regulatory, client-specific, and accreditation compliance timelines • Conduct direct, professional Peer-to-Peer telephonic reviews with prescribing physicians and advanced practice providers • Discuss denial rationales, clinical alternatives, and documentation requirements • Handle escalated, sensitive, or emotionally charged phone inquiries from members and providers • Balance clinical policy compliance with empathy and a customer-service mindset • Document verbal discussions, clinical rationales, and final appeal determinations in the internal utilization management platform • Serve as a subject matter expert and escalation resource for Clinical Pharmacist I and Pharmacy Support Specialist teams • Identify trends in clinical appeals and provider pushback • Provide structured feedback to clinical leadership to help optimize formulary design and criteria documentation • Perform other duties as required

🎯 Requirements

• Doctor of Pharmacy (PharmD) degree from an accredited institution • Active, unrestricted pharmacist license in your state of residence • Minimum of 1–2 years of direct experience in managed care, utilization management, or pharmacy benefit management (PBM) operations, with a strong preference for candidates who have specifically handled clinical appeals • Exceptional verbal communication and active listening skills • Proven ability to confidently and professionally navigate complex clinical phone conversations with physicians and anxious members • Advanced analytical skills to critically evaluate complex medical literature and chart notes • Ability to translate technical clinical parameters into clear, logical, and defensible rationales • Highly organized, self-motivated, and capable of managing complex caseloads independently within a virtual team environment • Familiarity with high-cost specialty medication classes, oncology pipelines, or rare disease therapeutics • Direct experience working within specialized PBM processing architectures, external portal structures, and clinical drug databases (e.g., Medi-Span, First Databank) • Deep working knowledge of URAC, NCQA, and CMS appeal compliance standards • Ability to work well with others in a collaborative environment • Ability to get things done with resources you don’t control • Willingness to admit you don’t know and ask for help • Constant curiosity and a drive to problem solve • Desire to learn and grow on a continuous basis