Clinical Pharmacist (Utilization Management)

Position Summary:

We are seeking a Utilization Management Pharmacist to support a high-volume review team by evaluating cases for medical necessity, prior authorizations, and clinical appropriateness. This is a project-based contract role with the potential for a permanent opportunity based on future budget approval.

Key Responsibilities:

• Review and evaluate prior authorization requests for medical necessity and clinical appropriateness.
• Process cases efficiently through assigned work queues, with a target of 20 case reviews per day.
• Interpret and apply prescription formularies, clinical guidelines, and utilization management criteria.
• Collaborate with pharmacists, providers, and support staff to ensure timely and accurate case determinations.
• Document reviews and decisions accurately within the appropriate systems.
• Work independently while maintaining quality and productivity standards.

Qualifications:

• Current New York State Pharmacist License (required).
• Previous utilization management or prior authorization experience with a health plan/payer preferred.
• Retail pharmacy experience with involvement in the prior authorization process will also be considered.
• Strong knowledge of prescription formularies and pharmacy benefit management processes.
• Excellent communication and interpersonal skills.
• Proficient in Microsoft Office applications and comfortable learning new systems.
• Ability to work independently in a fast-paced environment.

Schedule:

• Monday–Friday, 8:30 AM – 5:00 PM
• Occasional weekend or holiday coverage may be required based on business needs.

Location:

Candidates must reside within the Excellus service area in Upstate New York, including locations from Buffalo to Albany.