Clinical Pharmacist: US Utilization & Appeals Expert

Private Advertiser; Taguig; On-site; PHP 400,000 - 700,000; Full time

Job summary

Private Advertiser is seeking a licensed Pharmacist with experience in US Healthcare, Managed Care, or Utilization Management to join our team in the Philippines. You will conduct medication utilization reviews for US insurance and apply CMS, FDA, InterQual, and MCG criteria to determine coverage.

The ideal candidate has 2–3 years of BPO experience in managed care or clinical pharmacy, strong clinical judgment, and excellent English communication skills to collaborate with physicians and nurses.

Qualifications

• Licensed Pharmacist with active license.
• 2–3 years BPO experience in managed care, clinical pharmacy, or utilization management.
• Experience with InterQual and MCG tools.
• Knowledge of Medicare Part D, Medicaid, and commercial insurance.

Responsibilities

• Conduct medication utilization reviews for US insurance.
• Review prior authorizations, step therapy, and quantity limit overrides.
• Apply CMS, FDA, InterQual, and MCG clinical criteria.
• Make and document accurate coverage determinations.
• Support appeals and grievance reviews.
• Collaborate with physicians, nurses, and other healthcare teams.
• Monitor utilization trends and ensure regulatory compliance.

Skills

Clinical Pharmacy

Critical Thinking

Communication

English Proficiency

Regulatory Knowledge

Education

Pharmacy degree

Pharmacist license

Tools

InterQual

MCG

Claims systems

Job description

Private Advertiser is seeking a licensed Pharmacist with experience in US Healthcare, Managed Care, or Utilization Management to join our team in the Philippines. You will conduct medication utilization reviews for US insurance and apply CMS, FDA, InterQual, and MCG criteria to determine coverage.

The ideal candidate has 2–3 years of BPO experience in managed care or clinical pharmacy, strong clinical judgment, and excellent English communication skills to collaborate with physicians and nurses.