Pharmacist – Utilization Management, UM

• Review requests for medication coverage determination for prior authorization and appeals
• Evaluate clinical information provided by physicians against medical policy criteria through the Utilization Review system
• Use clinical knowledge, medical policy, and physician requests to make coverage determinations
• Conduct research beyond medical policy review when needed
• Update system records to ensure claims are properly routed and paid
• Perform other duties as assigned

• Bachelor's degree in Pharmacy
• 1–3 years in Pharmacy
• Registered Pharmacist
• Oral & Written Communication Skills
• General Computer Skills
• Problem Solving & Decision Making
• Compliance
• Prioritizing
• Compliance with HIPAA, privacy policies, information security policies, Code of Business Conduct, applicable laws, regulations, company policies, and training requirements
• Must protect confidential customer information and covered information

Demonstrates expertise in medication coverage determination and appeals, utilizing clinical knowledge and medical policy to make informed decisions. Proficient in compliance with HIPAA and other regulatory requirements while ensuring the protection of confidential information.

• Bachelor's Degree In Pharmacy
• Registered Pharmacist
• Medication Coverage Determination
• Compliance With HIPAA
• Problem Solving & Decision Making

• Oral & Written Communication Skills
• Prioritizing

• Pharmacy
• Medical Policy
• Confidential Customer Information
• Information Security Policies
• Code Of Business Conduct

• Utilization Review System
• General Computer Skills