PBM Utilization Management Pharmacist (REMOTE)

Unitas; Town of River Falls (WI); Hybrid; USD 90,000 - 130,000; Full time

Job summary

UNITAS in Wisconsin is seeking an Utilization Management Pharmacist to review prior authorizations and support clinical programs. This role blends clinical decision-making with a strong focus on service delivery in a fast-paced, collaborative environment.

You will document decisions, stay current with guidelines, and ensure compliance across Commercial, Exchange, Medicare, and Medicaid plans. After-hours and weekend coverage is required on a rotating schedule.

Qualifications

• Doctor of Pharmacy or PharmD required.
• Minimum 2 years of pharmacy practice experience.
• Strong written and oral communication skills.
• Ability to manage multiple priorities in a high-volume setting.
• Availability to work after hours, weekends, and holidays on rotating schedule.

Responsibilities

• Review prior authorization requests and appeals with evidence-based decisions.
• Ensure compliance with federal, state, and internal regulations across plans.
• Document clinical decisions and maintain records per URAC/NCQA standards.
• Provide empathetic support to members, prescribers, and pharmacies via phone.
• Stay current with prescribing guidelines and internal policies.
• Follow HIPAA guidelines to protect privacy.
• Identify and report fraud, waste, and abuse.
• Support training and development of team members.
• Assist leadership with special projects and process improvements.

Skills

Communication skills

Organizational skills

After-hours availability

Education

Doctor of Pharmacy degree

Bachelor’s degree in Pharmacy

Job description

UNITAS provides clinical staffing and consulting solutions, including contract staff augmentation, permanent talent recruiting, consulting, and clinical coaching. Our extensive experience includes Pharmacy Benefit Management, Long-Term Care, Retail Pharmacy, Hospital, and Leadership, enabling us to connect the best clinical talent with outstanding companies. We know clinicians because we are clinicians!

Position Summary:

The Utilization Management Pharmacist plays a vital role in promoting safe, effective, and appropriate medication use. This position is responsible for reviewing prior authorization requests, supporting clinical programs, and providing expert guidance to members, providers, and pharmacies. The role combines clinical decision-making with a strong focus on service excellence in a fast-paced, collaborative environment.

Position Responsibilities:

• Review and make timely, evidence-based decisions on prior authorizations, appeals, and override requests using clinical guidelines and benefit criteria.
• Ensure compliance with federal, state, and internal regulations across Commercial, Exchange, Medicare, and Medicaid plans.
• Accurately document clinical decisions and maintain thorough records in accordance with regulatory and accreditation (URAC/NCQA) utilization review standards.
• Provide clear, empathetic support to members, prescribers, and pharmacies by responding to clinical inquiries via phone, demonstrating professionalism, active listening, and a patient-centered approach.
• Stay current with clinical prescribing guidelines, internal policies, and regulatory changes, and apply them to daily responsibilities.
• Follow all internal procedures, job aids, and HIPAA guidelines to protect patient privacy and data security.
• Identify and report potential fraud, waste, and abuse.
• Support training and development of new and existing team members as needed.
• Assist leadership with special projects, process improvements, and operational initiatives

Minimum Qualifications:

• Bachelor’s or Doctor of Pharmacy degree
• Minimum of 2 years of pharmacy practice experience
• Strong communication, writing, and organizational skills
• Ability to manage multiple priorities in a high-volume, metric-driven environment
• Availability to work after hours, weekends, and holidays on a rotating schedule

Preferred Qualifications:

• Call center experience
• Minimum of 6 months prior authorization or utilization management experience
• Experience in managed care or pharmacy benefit management (PBM)

We provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.