Career Opportunities International

Pharmacist

• Evaluate, research, and adjudicate first- and second-level clinical appeals and highly complex drug coverage requests against established plan criteria and evidence-based clinical guidelines
• Utilize comprehensive comparative effectiveness data, medical literature, and patient-specific charts to determine medical necessity for non-formulary or specialized therapies
• Complete appeal determinations within strict regulatory, client-specific, and accreditation compliance timelines
• Conduct direct, professional Peer-to-Peer telephonic reviews with prescribing physicians and advanced practice providers
• Discuss denial rationales, clinical alternatives, and documentation requirements
• Handle escalated, sensitive, or emotionally charged phone inquiries from members and providers
• Balance clinical policy compliance with empathy and a customer-service mindset
• Document verbal discussions, clinical rationales, and final appeal determinations in the internal utilization management platform
• Serve as a subject matter expert and escalation resource for Clinical Pharmacist I and Pharmacy Support Specialist teams
• Identify trends in clinical appeals and provider pushback
• Provide structured feedback to clinical leadership to help optimize formulary design and criteria documentation
• Perform other duties as required

Utilization Management Clinical Pharmacist II

Operations

• Lead the day-to-day operations of the Pharmacy Support Specialist organization
• Ensure efficient handling of inbound and outbound member and provider interactions
• Build and manage Supervisors responsible for front-line Pharmacy Support Specialists
• Lead Training and Quality Assurance resources to ensure consistent onboarding, coaching, and performance standards
• Ensure adequate staffing, workload balancing, and operational coverage
• Monitor operational performance and resolve issues affecting productivity, customer experience, or quality
• Foster accountability, collaboration, continuous improvement, and employee engagement
• Coach and develop Supervisors and conduct regular performance reviews
• Partner with Training and QA resources to identify skill gaps and implement development programs
• Serve as operational business owner for the Pharmacy Operations CRM platform
• Prioritize CRM enhancements with Technology, Product, and Business stakeholders
• Streamline workflows, eliminate manual processes, and improve efficiency through automation
• Lead continuous improvement initiatives and evaluate scalable operational solutions
• Support CRM implementation, testing, user acceptance, and change management
• Develop, monitor, and analyze service levels, average handle time, productivity, quality scores, case accuracy, customer experience metrics, and backlog management
• Produce operational reports and dashboards for senior leadership
• Analyze trends, identify root causes, and develop action plans
• Collaborate with Pharmacy Operations, Clinical, Technology, Client Services, and other operational teams
• Participate in strategic initiatives focused on scalability and service excellence
• Communicate performance, risks, and improvement opportunities to leadership

Operations Manager, Pharmacy Operations

• Serve as the primary clinical anchor, mentor, and escalation point for Clinical Pharmacist I and II teams
• Provide operational and clinical support for complex case rationales, ambiguous criteria interpretation, and difficult Peer-to-Peer strategies
• Provide daily guidance, mentorship, and clinical coaching to team members
• Manage clinical pharmacist scheduling and PTO requests
• Plan and balance team capacity against fluctuating case volumes to maintain staffing and turnaround-time SLAs
• Collaborate with the Clinical Pharmacist Operations Manager on performance improvement and mentorship frameworks
• Participate in recruitment and interviewing
• Resolve operational or systemic friction in the pharmacist queue or escalate issues with structured solutions
• Lead ongoing clinical training and continuing education initiatives
• Design and update clinical reference materials, tip sheets, and training modules
• Monitor adherence to quality benchmarks and compliance standards, including URAC, NCQA, and CMS guidelines
• Oversee or execute sensitive clinical appeals and complex drug coverage requests
• Contribute to internal clinical quality audits
• Liaise with the Pharmacy Support Specialist Supervisor for end-to-end routing from intake to final clinical decision
• Lead or contribute to specialized operational workstreams, client-facing implementations, and product optimization tasks
• Perform other duties as required

Utilization Management Clinical Pharmacist II

Operations Manager, Pharmacy Operations

Clinical Pharmacist Supervisor