Specialty Sub

Job Title:

Remote Clinical Utilization Management Pharmacist Job Description

This remote Clinical Utilization Management Pharmacist role focuses on performing detailed clinical reviews of specialty medication utilization management requests, including formulary exceptions, prior authorizations, step therapy, and quantity limit exceptions. You will apply sound clinical judgment to coverage determinations for complex and cutting-edge therapies, primarily oncology and other specialty areas, across Commercial, Medicare, and Medicaid lines of business (excluding Medicare claims processing).

The position offers an opportunity to transition away from retail pharmacy into a structured, collaborative environment with the potential for long-term conversion to a permanent role.

• Review and perform clinical evaluations for coverage determination requests related to prior authorization and other utilization management programs.
• Assess formulary exceptions, prior authorizations, step therapy, and quantity limit exception requests for approximately 500 specialty medications, including a high volume of injectable and infused products.
• Apply client-specific clinical criteria to determine whether prior authorization requests meet coverage requirements.
• Focus on specialty medications, with oncology representing the majority of cases, and additional cases in rheumatology, gastroenterology, neurology, dermatology, and other specialties.
• Ensure all clinical decisions reflect sound judgment, adherence to policies, and appropriate documentation.
• Consult directly with health care providers regarding non-formulary and clinical product coverage issues through inbound and outbound calls.
• Communicate clearly and professionally with prescribers, office staff, and other stakeholders to clarify clinical information and explain coverage determinations.
• Collaborate with a team of pharmacists to promote consistency and alignment in coverage decisions across the team.
• Escalate or transfer cases to the designated denial team when the determination is leaning toward denial, recognizing that final denials are completed by medical doctors.
• Use multiple computer systems and platforms simultaneously to research criteria, document decisions, and process cases efficiently.
• Meet or exceed productivity expectations by completing an average of approximately 30 cases per day while maintaining high accuracy and quality.
• Participate in regular communication with supervisors, senior pharmacists, technicians, and team members via messaging platforms, phone, and video calls.
• Engage in training sessions, team meetings, and routine one-on-one meetings with supervisors using video conferencing tools.
• Seek guidance from senior pharmacists as needed and contribute to a supportive, knowledge-sharing team culture.
• Demonstrate strong attendance, accountability, and responsiveness in a fully remote work environment.
• Adapt to process changes, new criteria, and evolving clinical guidelines with agility and a continuous learning mindset.
• Complete required training activities, including instructor-led sessions, videos, worksheets, and practice case reviews, and begin handling live cases by the third or fourth week of training.
• Maintain compliance with all regulatory, legal, and organizational requirements related to pharmacy practice and utilization management.
• Perform other related duties as assigned to support team and organizational goals.

• Doctor of Pharmacy (PharmD) or Bachelor of Science in Pharmacy degree.
• Current pharmacist license in good standing with a State Board of Pharmacy in the United States.
• Five (5) or more years of work experience in retail, managed care, or clinical pharmacy.
• Experience working as a pharmacist in a…