The Utilization Management Clinical Pharmacist is responsible for playing a critical role in optimizing medication use, improving member outcomes, and ensuring regulatory compliance. This position serves as a clinical expert supporting medical injectable and specialty medication utilization management, formulary development, clinical policy creation, and all other clinical pharmacy initiatives as needed. This role helps ensure members receive safe, effective, evidence-based, and cost-conscious drug therapy while supporting organizational quality, compliance, and operational goals.
KEY RESPONSIBILITIES:- Review prior authorization requests for medical injectable, specialty, and other high-cost medications using evidence-based clinical criteria, regulatory requirements, and benefit design.
- Approve or deny medication requests within established turnaround time requirements while ensuring consistency and clinical appropriateness.
- Collaborate with pharmacy technicians, medical directors, and other clinicians to facilitate timely and accurate utilization management decisions.
- Provide clinical consultation regarding complex medication requests and coverage determinations.
- Support the development, implementation, and maintenance of medical drug utilization management programs.
- Develop and maintain evidence-based clinical criteria, treatment policies, and prior authorization guidelines.
- Perform annual policy reviews and update clinical criteria based on emerging evidence, clinical guidelines, and regulatory changes.
- Monitor new drug approvals and recommend appropriate utilization management strategies.
- Develop educational materials and clinical communications for providers and internal stakeholders.
- Participate in provider outreach and academic detailing initiatives focused on evidence-based prescribing and formulary optimization.
- Support provider newsletters, educational programs, and clinical training initiatives.
- Perform other related job duties as required or assigned.
QUALIFICATIONS:- Strong knowledge of managed care pharmacy, utilization management, and formulary management principles.
- Demonstrated understanding of Medicare, Commercial, and pharmacy benefit management operations.
- Ability to interpret and apply clinical literature, treatment guidelines, and regulatory requirements.
- Strong analytical, organizational, critical thinking, and decision-making skills.
- Excellent written, verbal, and presentation skills.
- Ability to effectively collaborate across multidisciplinary teams.
- Proficiency with Microsoft Office applications and pharmacy information systems.
- Ability to work remotely will be provided to qualified candidates.
- On call coverage for weekends and holidays necessary on a scheduled rotation.
- Successful completion of Health Care Sanctions background check.
EDUCATION/EXPERIENCE:- Doctor of Pharmacy (PharmD) or Bachelor of Science in Pharmacy from an accredited School of Pharmacy.
- Active, unrestricted pharmacist license in any United States jurisdiction.
- A minimum of five years of clinical pharmacy experience in managed care pharmacy, health plan pharmacy, pharmacy benefit management, specialty pharmacy, hospital pharmacy, or a related clinical practice setting.
- Prior experience reviewing prior authorization requests for medical injectable and specialty medications with Medicare Part D and Commercial lines of business preferred.
