Remote Utilization Management Pharmacist Prior Auth Expert

Capital Rx Inc.; New York (NY); Remote; USD 110,000 - 150,000; Full time

Job summary

Judi Health in the United States is seeking a Utilization Management Pharmacist to review prior authorizations and support clinical programs. This role combines clinical decision-making with service excellence in a fast-paced, collaborative environment.

You will assess authorization requests, ensure regulatory compliance, and provide expert guidance to members, providers, and pharmacies while maintaining patient privacy and data security.

Qualifications

• Minimum 6–12 months of prior authorization or utilization management experience.
• Active, unrestricted pharmacist license.
• Bachelor's or Doctor of Pharmacy degree.
• Minimum 2 years of pharmacy practice experience.
• Experience in managed care or PBM.
• 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.
• Available to work 2p-11p ET shift.

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 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

Skills

Communication

Organizational skills

Multi-tasking

Availability after hours

PBM experience

Prior authorization

Utilization management

Education

Bachelor's or Doctor of Pharmacy

Job description

Judi Health in the United States is seeking a Utilization Management Pharmacist to review prior authorizations and support clinical programs. This role combines clinical decision-making with service excellence in a fast-paced, collaborative environment.

You will assess authorization requests, ensure regulatory compliance, and provide expert guidance to members, providers, and pharmacies while maintaining patient privacy and data security.