Pharmacist: Utilization Management & Prior Authorization

Jobtailor; Pennsylvania; On-site; USD 70,000 - 95,000; Full time

Job summary

Jobtailor in Pennsylvania seeks a Pharmacy reviewer to determine medication coverage determinations and appeals. The role uses clinical knowledge and medical policy to decide coverage asks, with research when needed, and updates the system to route claims correctly.

Candidate should have a Pharmacy degree, be a registered pharmacist, and demonstrate strong communication and problem-solving skills, plus HIPAA and information security awareness.

Qualifications

• Bachelor's degree in Pharmacy.
• 1–3 years in Pharmacy.
• Registered Pharmacist.
• Oral & Written Communication Skills.
• General Computer Skills.
• Problem Solving & Decision Making.
• Compliance with HIPAA and related policies.
• Must protect confidential information.

Responsibilities

• Review requests for medication coverage determinations for prior authorization and appeals.
• Evaluate clinical information against medical policy criteria through the Utilization Review system.
• Use clinical knowledge, medical policy, and physician requests to make coverage determinations.
• Conduct research beyond medical policy review when needed.
• Update system records to ensure claims are properly routed and paid.
• Perform other duties as assigned.

Education

Bachelor's degree in Pharmacy

Tools

Utilization Review System

Job description

Jobtailor in Pennsylvania seeks a Pharmacy reviewer to determine medication coverage determinations and appeals. The role uses clinical knowledge and medical policy to decide coverage asks, with research when needed, and updates the system to route claims correctly.

Candidate should have a Pharmacy degree, be a registered pharmacist, and demonstrate strong communication and problem-solving skills, plus HIPAA and information security awareness.