Job Description

Remote Clinical Utilization Management Pharmacist

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.

Responsibilities

• 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, 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 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.

Essential Skills

• 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 retail environment, with specialty pharmacy experience preferred.
• Ability to make independent clinical decisions and exercise sound clinical judgment in complex cases.
• Strong ability to prioritize tasks and manage multiple cases and projects simultaneously in a high-volume environment.
• Demonstrated drive to deliver results and consistently meet productivity and quality expectations.
• Motivated self-starter who can work independently without constant direction while remaining engaged with the team.
• Flexibility, resourcefulness, and adaptability to change in processes, criteria, and workload demands.
• Proficiency in learning and navigating new computer systems and applications quickly.
• Comfort working with multiple monitors and managing multiple platforms and resources at the same time.
• Proficiency with Microsoft Word and Excel.
• Ability to type at least 45 words per minute.
• Strong verbal and written communication skills, including the ability to communicate clinical information clearly to health care providers.
• Comfort conducting inbound and outbound calls with prescribers and other health care professionals.
• High attention to detail and accuracy in clinical evaluation and documentation.
• Ability to maintain focus, problem-solve, and demonstrate learning agility in a remote work setting.
• Comfort using collaboration tools such as messaging platforms, phone, and video conferencing for daily communication.

Additional Skills & Qualifications

• Experience in specialty pharmacy, particularly with injectable and infused medications, is preferred.
• Experience with oncology, rheumatology, gastroenterology, neurology, dermatology, or other specialty therapeutic areas is beneficial.
• Prior experience in pharmacy benefits management (PBM) is acceptable but not required.
• Experience with prior authorization, utilization management, or pharmacy benefit coverage determinations is advantageous.
• Familiarity with pharmacy benefits management systems and workflows is a plus.
• Exposure to compounding pharmacy practice is a plus.
• Comfort using tools such as AutoHotkey or similar productivity utilities is beneficial.
• Demonstrated ability to quickly learn and apply client-specific clinical criteria and guidelines.
• Strong accountability and attendance record in previous roles.
• Receptiveness to feedback and commitment to continuous improvement.
• Team-oriented mindset with the ability to work independently while contributing to a collaborative culture.
• Willingness to provide transparency regarding licensure status, including any prior disciplinary actions if applicable.
• Interest in transitioning from retail pharmacy to a remote, structured clinical review environment.
• Openness to long-term engagement, with the potential for conversion to a permanent role subject to business needs.

Work Environment

This role is fully remote and based in the United States, with eligibility to work from any state except Hawaii and Alaska. Candidates may hold a pharmacist license in any U.S. state; however, they must reside in a U.S. state other than those excluded and may not live in a U.S. territory or hold only a territory license. The position operates in a structured, technology-driven environment using multiple monitors, various clinical and administrative platforms, Microsoft applications, and tools such as AutoHotkey to support efficient case processing. After training, standard schedules are fixed and fall within 10:00 a.m.6:00 p.m. CST, 11:00 a.m.7:00 p.m. CST, or 12:00 p.m.8:00 p.m. CST. Once assigned, the shift remains permanent, though business needs may occasionally require adjustments. Candidates in Pacific Time typically work the 12:00 p.m.8:00 p.m. CST shift (10:00 a.m.6:00 p.m. PST), and candidates in Mountain Time typically work the 11:00 a.m.7:00 p.m. CST shift (10:00 a.m.6:00 p.m. MST). Team members in Central or Eastern Time may be assigned to any of the three shifts, and while efforts are made to accommodate preferred schedules, candidates must be comfortable with the latest shift if needed. The role is full-time with no part-time options, and candidates should plan for a full-time schedule with optional overtime during peak season, typically November through May. There are no regular weekend shifts, and for the current cycle, holidays in 2026 are covered and not required, though future holiday coverage (including 2027 and beyond) may be determined through a team bid and seniority process. Contractors begin with an allotment of unpaid time off per year, with availability and increases dependent on business needs and seniority. Time off is bid annually, and there is no time off permitted during the first three weeks of the initial training period. Training is conducted Monday through Friday, generally between 8:00/9:00 a.m. and 4:30/5:30 p.m. CST for the first three weeks, with schedules transitioning to the assigned shift afterward. The training program lasts approximately 16 weeks and includes instructor-led sessions, videos, worksheets, and practice case reviews, with pharmacists to handle live cases in the third or fourth week. Time off during training is minimal, with limited exceptions for holidays or emergencies. Additional restrictions apply during peak periods, including no time off during Thanksgiving week (with Thanksgiving Day and the following day off) and limits on extended time off beyond one to two days. The culture emphasizes strong communication, regular virtual touchpoints, and support

Job Tags

Permanent employment, Full time, Part time, For contractors, Work experience placement, Live in, Work at office, Monday to Friday, Shift work, Weekend work, Afternoon shift

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