Clinical Pharmacist: Prior Authorization & Utilization Mgmt

DME Service Solutions; Taguig; On-site; PHP 5,339,000 - 7,224,000; Full time

Job summary

DME Service Solutions in the US seeks a Pharmacist for Utilization Management to review prior authorizations and appeals, applying medical policy criteria and CMS guidelines. You will evaluate clinical information provided by physicians and determine coverage determinations.

Work includes conducting prospective, concurrent, and retrospective reviews, collaborating with clinicians and payers, and documenting decisions in UR systems to ensure compliant, timely outcomes.

Qualifications

• Pharmacy degree and licensure required.
• 1-3 years in managed care, clinical pharmacy, or utilization management.
• Strong knowledge of Medicare Part D, Medicaid formularies, and commercial insurance benefits.
• Familiarity with drug databases, claims systems, and prior authorization platforms.
• Excellent communication and critical thinking skills.

Responsibilities

• Make coverage determinations by evaluating requests for prior authorization against medical policy.
• Conduct utilization reviews for medications and pharmacy services in US insurance.
• Research beyond medical policy to support coverage decisions.
• Document decisions in UR systems per regulatory requirements.
• Support appeals and grievance processes with clinical input.

Skills

Communication

Critical thinking

Utilization management

Pharmacist

Education

Pharmacy degree (PharmD)

Tools

UR systems

Drug databases

Claims systems

Prior authorization platforms

Job description

DME Service Solutions in the US seeks a Pharmacist for Utilization Management to review prior authorizations and appeals, applying medical policy criteria and CMS guidelines. You will evaluate clinical information provided by physicians and determine coverage determinations.

Work includes conducting prospective, concurrent, and retrospective reviews, collaborating with clinicians and payers, and documenting decisions in UR systems to ensure compliant, timely outcomes.