Pharmacist – Utilization Management, UM

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

• Review requests for medication coverage determination for prior authorization and appeals
• Evaluate clinical information provided by physicians 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

Requirements

• Bachelor's degree in Pharmacy
• 1–3 years in Pharmacy
• Registered Pharmacist
• Oral & Written Communication Skills
• General Computer Skills
• Problem Solving & Decision Making
• Compliance
• Prioritizing
• Compliance with HIPAA, privacy policies, information security policies, Code of Business Conduct, applicable laws, regulations, company policies, and training requirements
• Must protect confidential customer information and covered information

Core Competencies

Demonstrates expertise in medication coverage determination and appeals, utilizing clinical knowledge and medical policy to make informed decisions. Proficient in compliance with HIPAA and other regulatory requirements while ensuring the protection of confidential information.

Highest-signal resume keywords

• Bachelor's Degree In Pharmacy
• Registered Pharmacist
• Medication Coverage Determination
• Compliance With HIPAA
• Problem Solving & Decision Making

ATS Optimization Keywords

Soft Skills

• Oral & Written Communication Skills
• Prioritizing

Industry Keywords

• Pharmacy
• Medical Policy
• Confidential Customer Information
• Information Security Policies
• Code Of Business Conduct

Tools & Technologies

• Utilization Review System
• General Computer Skills