Clinical Pharmacist- Utilization Management
Core
Review utilization management requests for coverage to ensure clinical appropriateness and cost-effectiveness, developing clinical policies and programs like Prior Authorization and Step Therapy.
Role type
Senior Clinical Pharmacist (Utilization Management)
Builds
Pharmacy benefit management services including coverage determinations, prior authorization, and step therapy programs for clients.
Domain
Healthcare / Pharmacy Benefit Management (PBM)
Required skills
Clinical pharmacy knowledge, utilization management expertise, policy development, state/federal guideline compliance, inter-rater reliability analysis, project leadership, strategic decision rationale communication
Preferred skills
Managed care (PBM or health plan) prior authorization experience, multi-state licensure capability
Technologies
None stated
Responsibilities
Review UM requests for coverage appropriateness and cost-effectiveness; Coordinate with Pharmacy technicians, Pharmacists, and Medical Directors; Ensure cases meet State/Federal guidelines and turnaround times; Discuss clinical strategy with prescribers; Participate in quality review and inter-rater reliability processes; Support P&T process and develop therapeutic class/drug monographs; Research and develop UM programs (Prior Authorization, Step Therapy, Quantity Limit, Coverage Determination).