Clinical Utilization Management Pharmacist

Job not on LinkedIn

🔥 1 minute ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

💊 Pharmacist

👻 Ghost score 10%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

Navitus Health Solutions

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2003

💼 Consulting

🛡️ Insurance

🏥 Healthcare

Consulting • Insurance • Healthcare

Navitus Health Solutions is a pharmacy benefit manager (PBM) that provides transparent, people-centered pharmacy benefit solutions to health plans, employers, government programs and other plan sponsors. The company operates a 100% pass-through, cost-plus model that emphasizes lowering medication costs, managing formularies, specialty drug management (including a cost-plus specialty pharmacy), claims adjudication, pharmacy network management, and member enablement and support services. Navitus positions itself as a fiduciary partner focused on affordability, compliance, clinical quality and improving health outcomes through tailored PBM services and digital health integrations.

📋 Description

• Serve as the clinical expert for specialty medications across pharmacy and medical benefits. • Communicate with physicians, nurses, pharmacists, members, clients, and consultants regarding high-cost cases, dose management, genetic testing, therapeutic substitutions, and specialty-drug cost management. • Manage prior authorization, high-cost cases, claims editing, and clinical policy development. • Conduct prior authorization outreach to prescribers to obtain clinical information, clarify requests, and support timely case resolution. • Communicate with prescribers and clinical stakeholders by phone, email, or fax regarding prior authorization requests, clinical documentation, and benefit requirements. • Explain utilization management criteria, coverage determinations, and appropriate therapeutic alternatives through evidence-based clinical conversations. • Provide prior authorization guidance, clinical context, and support for member-facing teammates. • Communicate directly with members as needed about prior authorization questions and clinical or coverage-related information. • Develop clinical programs for medical and pharmacy benefit management. • Define, document, and deliver results for plan sponsors. • Evaluate and summarize clinical literature and financial implications of medication management options. • Present clinical and cost-effectiveness information as a subject matter expert. • Perform other duties as assigned.

🎯 Requirements

• Bachelor’s degree in Pharmacy or PharmD degree required. • Current, unrestricted licensure as a Registered Pharmacist in the state of residence, or the ability to gain reciprocity within 4 months, may be required based on state of residence laws or client contracts. • Other State Pharmacy Licenses may be required as business need dictates. • Board of Pharmacy Certification preferred for Pharmacotherapy, Ambulatory Care or Oncology Care. • Pharmacy experience in retail, hospital, managed care, or other pharmacy-related setting required. • Experience and knowledge in Pharmacy and Medical specialty benefits required. • Proficiency in Microsoft Excel, PowerPoint, and Word required. • Experience with physician-facing clinical communication preferred. • Participate in, adhere to, and support compliance program objectives. • Ability to consistently interact cooperatively and respectfully with other employees. • Work schedule: M-F 8am to 5pm.

🏖️ Benefits

• Top of the industry benefits for Health, Dental, and Vision insurance • 20 days paid time off • 4 weeks paid parental leave • 9 paid holidays • 401K company match of up to 5% - No vesting requirement • Adoption Assistance Program • Flexible Spending Account • Educational Assistance Plan and Professional Membership assistance • Referral Bonus Program – up to $750!