Clinical Pharmacy Specialist – Utilization Management

About the role

The Clinical Pharmacy Specialist supports pharmacy operations across all business lines by managing utilization, formulary support, appeals, grievances, and audit reporting. The role ensures timely, accurate coverage decisions for prescription drugs and medical benefits.

Key responsibilities

• Process prior authorizations for Medicare Part B, Part D, and commercial plans, including J and Q code drugs.
• Track, triage, and determine when pharmacist review is required for coverage requests.
• Monitor turnaround times, gather additional information from providers, and communicate decisions.
• Prepare correspondence, reports, spreadsheets, and maintain policies and procedures.
• Provide project‑management assistance and support member/provider calls regarding authorizations and benefit inquiries.
• Coordinate intake and processing of pharmacy and medical authorization and appeal requests, performing preliminary reviews and escalating as needed.

Required profile

• Experience reviewing medication coverage under pharmacy and medical benefits.
• Ability to supervise and direct support services for pharmacy operations.
• Strong problem‑solving skills with a focus on process improvement.
• Professional, courteous communication with physicians, providers, and members.

Required skills

• Utilization Management
• Prior Authorization
• Pharmacy Benefit Knowledge
• Medicare Part B & D familiarity
• J‑code and Q‑code drug handling

What we offer

• Opportunity to work within a multidisciplinary pharmacy team.
• Professional development in pharmacy benefit management.