Remote Clinical Pharmacy Specialist - Prior Authorization

UPMC Senior Communities; Pittsburgh (Allegheny County); Remote; USD 95,000 - 130,000; Full time

Job summary

UPMC Health Plan is seeking a full-time Clinical Pharmacy Specialist to support the Prior Authorization Team within Pharmacy Services. This is a work-from-home daytime role (8:00 a.m.–5:00 p.m. EST) and requires PA licensure or eligibility for licensure.

The clinical pharmacist will review utilization management requests and participate in appeals while ensuring compliance with NCQA and CMS standards. Responsibilities include clinical review of prior authorization, step therapy, and quantity

Qualifications

• Bachelor of Science Degree in Pharmacy and/or Doctor of Pharmacy from an accredited U.S. School of Pharmacy.
• Experience in pharmacy benefit management, insurance, managed care preferred.
• Effective communication skills, both written and oral.
• Strong analytical ability and organizational skills.
• Computer literacy for pharmacy programming, word processing, data management.

Responsibilities

• Perform clinical review of Prior Authorization, Step Therapy, Quantity Limit and other utilization management requests per quality and time standards.
• Critically review utilization management requests against standard clinical criteria and policies.
• Participate in a clinical call queue to answer inquiries from internal and external stakeholders.
• Participate in the pharmacy appeals process and represent in fair hearings when needed.
• Contribute to other operational initiatives as assigned.
• Foster and maintain collaborative relationships with customers.
• Work independently in a virtual team setup with confidentiality.
• Demonstrate drug information skills for complex reviews.
• Understand DHS, CMS, PID, NCQA requirements relevant to clinical operations.
• Attend meetings, committees, and work groups; mentor students/residents if applicable.

Skills

Pharmacy degree

Strong communication

Analytical skills

Organizational skills

Computer literacy

Education

Pharm.D/Bachelor of Science in Pharmacy

Job description

UPMC Health Plan is seeking a full-time Clinical Pharmacy Specialist to support the Prior Authorization Team within Pharmacy Services. This is a work-from-home daytime role (8:00 a.m.–5:00 p.m. EST) and requires PA licensure or eligibility for licensure.

The clinical pharmacist will review utilization management requests and participate in appeals while ensuring compliance with NCQA and CMS standards. Responsibilities include clinical review of prior authorization, step therapy, and quantity