Utilization Management Clinical Pharmacist II

Career Opportunities International

. 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 .

Posted 9/22/2026full-timeRemote • United StatesJunior💰 $140,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical appeals evaluation and adjudication, utilizing advanced analytical skills to assess medical necessity and compliance with URAC, NCQA, and CMS standards. Proficient in managing complex caseloads while maintaining a customer-service mindset and effective communication with healthcare providers.

Highest-signal resume keywords

Doctor Of Pharmacy (PharmD)Active Pharmacist LicenseClinical Appeals ExperienceUtilization ManagementAnalytical Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Appeals EvaluationMedical Necessity AssessmentComparative Effectiveness Data AnalysisClinical Literature EvaluationDocumentation of Clinical Rationales

Soft Skills

Exceptional Verbal CommunicationActive ListeningEmpathyCollaborationProblem Solving

Tools & Technologies

Medi-SpanFirst DatabankClinical Drug DatabasesUtilization Management Platform

Certifications & Qualifications

Pharmacist License

Industry Keywords

Managed CarePharmacy Benefit Management (PBM)URAC ComplianceNCQA StandardsCMS Standards

About the role

Key responsibilities & impact

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

Requirements

What you’ll need

Doctor of Pharmacy (PharmD) degree from an accredited institution
Active, unrestricted pharmacist license in your state of residence
Minimum of 1–2 years of direct experience in managed care, utilization management, or pharmacy benefit management (PBM) operations, with a strong preference for candidates who have specifically handled clinical appeals
Exceptional verbal communication and active listening skills
Proven ability to confidently and professionally navigate complex clinical phone conversations with physicians and anxious members
Advanced analytical skills to critically evaluate complex medical literature and chart notes
Ability to translate technical clinical parameters into clear, logical, and defensible rationales
Highly organized, self-motivated, and capable of managing complex caseloads independently within a virtual team environment
Familiarity with high-cost specialty medication classes, oncology pipelines, or rare disease therapeutics
Direct experience working within specialized PBM processing architectures, external portal structures, and clinical drug databases (e.g., Medi-Span, First Databank)
Deep working knowledge of URAC, NCQA, and CMS appeal compliance standards
Ability to work well with others in a collaborative environment
Ability to get things done with resources you don’t control
Willingness to admit you don’t know and ask for help
Constant curiosity and a drive to problem solve
Desire to learn and grow on a continuous basis