Specialty Utilization Management Pharmacist

About the role

Curative is seeking a Specialty Utilization Management (UM) Pharmacist to lead prior authorization and utilization review activities for high‑cost specialty medications covered under the medical benefit. This remote position supports policy development, formulary management, and cross‑functional initiatives across both medical and pharmacy benefits.

Key responsibilities

• Perform prior authorization reviews and coverage determinations for provider‑administered therapies billed with J‑codes, Q‑codes, and other HCPCS codes.
• Evaluate medical necessity, dosing, site‑of‑care appropriateness, and adherence to evidence‑based clinical criteria.
• Manage clinical review processes, including adverse determinations, appeals, and internal review orders (IRO).
• Write, review, and update PA guidelines to align pharmacy and medical benefit strategies.
• Act as a clinical liaison between medical and pharmacy teams, providing training and education to internal and external stakeholders.
• Meet assigned metrics and turnaround times as defined by regulatory requirements.
• Collaborate with Medical Directors and interdepartmental staff to communicate utilization management strategies.
• Review and resolve member and provider complaints related to prior authorizations.

Required profile

• Active RPh licensure in the state of residence.
• Experience conducting prior authorization reviews for specialty medications.
• Strong knowledge of HCPCS coding (J‑codes, Q‑codes) and medical benefit processes.
• Ability to interpret clinical evidence and apply evidence‑based criteria.
• Excellent communication skills for stakeholder education and collaboration.

Required skills

• RPh licensure
• Familiarity with HCPCS coding and prior authorization workflows