Utilization Management Pharmacist: Prior Authorization

DME Service Solutions; Taguig; On-site; PHP 4,397,000 - 6,910,000; Full time

Job summary

DME Service Solutions seeks a Pharmacist for Utilization Management to review prior authorization requests and appeals, applying CMS and FDA criteria to determine medication coverage. You will collaborate with physicians and care teams, document decisions in UR systems, and support appeals with clinical input for US insurance plans.

Required are a pharmacy degree, active pharmacist license, and 1–3 years in managed care or UR, with strong Part D knowledge and regulatory compliance.

Qualifications

• Pharmacy College Graduate.
• Active Pharmacist license.
• 1–3 years of experience in managed care, clinical pharmacy, or utilization management.
• Must have experience with Medical Part D.
• 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.
• Ensure compliance with federal and state regulations, NCQA/URAC standards, and plan policies.

Responsibilities

• Make coverage determinations by evaluating physician requests for prior authorization or appeals against medical policy through the Utilization Review system.
• Update system records appropriately to ensure claims are properly routed and paid.
• Conduct research beyond medical policy review to make decisions on medication coverage requests.
• Conduct prospective, concurrent, and retrospective utilization reviews for medications and pharmacy services in US insurance.
• Apply clinical criteria (e.g., CMS guidelines, FDA labeling) to make coverage determinations.
• Review and process prior authorizations, step therapy, and quantity limit overrides.
• Collaborate with physicians, nurses, and customer service teams on clinical determinations.
• Document clinical decisions accurately within UR systems and according to regulatory requirements.
• Support appeals and grievance processes by reviewing denied claims and providing clinical input.
• Monitor and report utilization trends, potential fraud, waste, or abuse.

Skills

Pharmacist license

Managed care experience

Utilization management

Medical Part D knowledge

Medicare/Medicaid knowledge

Drug databases familiarity

Communication skills

Regulatory compliance

Education

Pharmacy degree

Tools

UR systems

Prior authorization platforms

Claims systems

Job description

DME Service Solutions seeks a Pharmacist for Utilization Management to review prior authorization requests and appeals, applying CMS and FDA criteria to determine medication coverage. You will collaborate with physicians and care teams, document decisions in UR systems, and support appeals with clinical input for US insurance plans.

Required are a pharmacy degree, active pharmacist license, and 1–3 years in managed care or UR, with strong Part D knowledge and regulatory compliance.