Utilization Management Clinical Pharmacist

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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 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 in a fast-paced environment • 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

🎯 Requirements

• Doctor of Pharmacy (PharmD) degree from an accredited institution • Active, unrestricted pharmacist license in your state of residence • Prior experience in managed care, utilization management, or pharmacy benefit management (PBM) operations • Strong clinical skills with the ability to critically evaluate and apply complex clinical data to individual case reviews • Self-motivated, highly organized, and capable of working effectively both independently and collaboratively in a virtual environment • A meticulous eye for detail with a proven ability to precisely follow and apply established plan criteria and protocols • Exceptional written and verbal communication skills, with a strong customer-service mindset

🏖️ Benefits

• Clinically appropriate, cost-effective medications • Compliance with strict quality, regulatory, and turnaround standards