Clinical Pharmacist – Medicare Utilization Management (Payer Side)

This job reviews requests for medication coverage determination for prior authorization review and appeals. Through the Utilization Review system, the Pharmacist for Utilization Management evaluates clinical information provided by the physician against medical policy criteria. The incumbent then uses his/her clinical knowledge compared to the policy and physician request to make a determination.

At times, the incumbent may conduct additional research beyond medical policy review to make coverage determinations.