Pharmacy Utilization Lead - Prior Authorization & Claims

Walker Healthforce, Inc.; Newark (NJ); Hybrid; USD 65,000 - 90,000; Full time

Benefits offered by this job

Competitive pay

Direct deposit

Medical, dental & vision

401k

Job summary

Walker Healthforce, Inc. in Newark, NJ is seeking a Pharmacy Utilization Management Specialist for a hybrid, contract role starting ASAP. This position offers 40 hours weekly with a W2 worker arrangement.

You will manage prior authorizations, assist members and providers with eligibility and claims issues, support formulary adherence, handle appeals, and contribute to ad-hoc reporting and program operations.

Qualifications

• 2+ years of third-party prescription program claim adjudication experience.
• 2+ years of Pharmacy Utilization Management Specialist experience.
• Prior customer service or service quality initiative experience.
• Experience with prior authorizations, pharmacy claims, coverage determinations, and medical criteria.
• Bachelor's degree in Health Care Management, Business, Pharmaceutical Administration, or related field (bonus).

Responsibilities

• Process prior authorization requests and evaluate medical necessity according to established criteria.
• Support members, physician offices, pharmacies, and internal stakeholders with eligibility, coverage, and claims issues.
• Assist with formulary compliance and generic dispensing initiatives.
• Process appeals, complaints, inquiries, and compliance-related issues.
• Support ad-hoc reporting and information requests; assist with Pharmacy department operations.
• Participate in training related to pharmacy services programs and operations.

Skills

Third-party prescription program claim

Pharmacy Utilization Management

Customer service / service quality

Prior authorizations & claims handling

Education

Bachelor's degree in Health Care Management, Business, Pharmaceutical Administration, or related field

Job description

Walker Healthforce, Inc. in Newark, NJ is seeking a Pharmacy Utilization Management Specialist for a hybrid, contract role starting ASAP. This position offers 40 hours weekly with a W2 worker arrangement.

You will manage prior authorizations, assist members and providers with eligibility and claims issues, support formulary adherence, handle appeals, and contribute to ad-hoc reporting and program operations.