Utilization Management Pharmacist - Remote/Medicare Focus

CommunityCare; Tulsa (OK); Remote; USD 110,000 - 140,000; Full time

Job summary

CommunityCare is seeking an Utilization Management Clinical Pharmacist to optimize medication use, improve outcomes, and ensure regulatory compliance. You will act as a clinical expert supporting medical injectables, specialty meds, formulary development, and clinical policy creation.

The role requires reviewing prior authorizations, collaborating with clinicians, and developing UM programs. This position emphasizes evidence-based decisions, cost-conscious care, and ongoing education for

Qualifications

• Doctor of Pharmacy (PharmD) or Bachelor of Science in Pharmacy from an accredited School of Pharmacy.
• Active, unrestricted pharmacist license in any United States jurisdiction.
• A minimum of five years of clinical pharmacy experience in managed care pharmacy, health plan pharmacy, PBM, specialty pharmacy, hospital pharmacy, or related setting.
• Prior experience reviewing prior authorization requests for medical injectable and specialty medications with Medicare Part D and Commercial lines of business preferred.

Responsibilities

• Review prior authorization requests using evidence-based clinical criteria, regulatory requirements, and benefit design.
• Approve or deny medication requests within established turnaround time requirements while ensuring consistency.
• Collaborate with pharmacy technicians, medical directors, and other clinicians to facilitate timely and accurate decisions.
• Provide clinical consultation regarding complex medication requests and coverage determinations.
• Support development and maintenance of medical drug utilization management programs.
• Develop and maintain evidence-based clinical criteria, treatment policies, and prior authorization guidelines.
• Perform annual policy reviews and update criteria based on evidence and regulatory changes.
• Monitor new drug approvals and recommend utilization management strategies.
• Develop educational materials and clinical communications for providers and internal stakeholders.
• Participate in provider outreach and academic detailing initiatives.
• Support provider newsletters, educational programs, and clinical training initiatives.
• Perform other related job duties as required or assigned.

Skills

Managed care pharmacy

Utilization management

Formulary management

Medicare Part D knowledge

Analytical skills

Organizational skills

Communication skills

Interdisciplinary collaboration

Pharmacy information systems

Remote work eligible

Education

PharmD or BS in Pharmacy

Active pharmacist license in US

Tools

Pharmacy information systems

Microsoft Office

Job description

CommunityCare is seeking an Utilization Management Clinical Pharmacist to optimize medication use, improve outcomes, and ensure regulatory compliance. You will act as a clinical expert supporting medical injectables, specialty meds, formulary development, and clinical policy creation.

The role requires reviewing prior authorizations, collaborating with clinicians, and developing UM programs. This position emphasizes evidence-based decisions, cost-conscious care, and ongoing education for