Pharmacy Specialist Level 1

Pay range - $17/hr. to $19/hr. on w2

Pharmacy Utilization Management Specialist

Job Summary

Responsible for processing prior authorization requests and supporting Pharmacy Services activities, including claim utilization analysis, prescription plan support, reporting, correspondence, and special projects. Ensures all activities meet departmental goals, quality standards, and regulatory requirements.

Key Responsibilities

• Process prior authorization requests by evaluating medical necessity and appropriateness based on established clinical criteria.
• Coordinate with members, physicians, pharmacies, and internal stakeholders regarding eligibility, coverage determinations, and claim issues.
• Work with physician and pharmacy offices to support formulary compliance and generic dispensing.
• Process appeals, complaints, executive inquiries, and compliance-related issues.
• Analyze pharmacy claims and utilization data and prepare ad hoc reports as requested.
• Recommend process improvements to increase department efficiency, accuracy, and productivity.
• Participate in client, member, and employee training related to pharmacy services and programs.
• Support daily pharmacy department operations and Medication Therapy Management programs.
• Provide support for various clinical programs within the Pharmacy Services department.

Requirements

• Bachelor's degree preferred in Healthcare Management, Business, Pharmaceutical Administration, or related field.
• Minimum 2 years of experience in third-party prescription claim adjudication.
• Minimum 2 years of experience as a Pharmacy Utilization Management Specialist.
• Previous customer service/service qualit