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Utilization Management Pharmacist (temp-to-hire)
Position Summary:
The Utilization Management Pharmacist plays a vital role in promoting safe, effective, and appropriate medication use. This position is responsible for reviewing prior authorization requests, supporting clinical programs, and providing expert guidance to members, providers, and pharmacies. The role combines clinical decision-making with a strong focus on service excellence in a fast-paced, collaborative environment.
Position Responsibilities:
Review and make timely, evidence-based decisions on prior authorizations, appeals, and override requests using clinical guidelines and benefit criteria.
Ensure compliance with federal, state, and internal regulations across Commercial, Exchange, Medicare, and Medicaid plans.
Accurately document clinical decisions and maintain thorough records in accordance with regulatory and accreditation (URAC/NCQA) utilization review standards.
Provide clear, empathetic support to members, prescribers, and pharmacies by responding to clinical inquiries via phone, demonstrating professionalism, active listening, and a patient-centered approach.
Stay current with clinical prescribing guidelines, internal policies, and regulatory changes, and apply them to daily responsibilities.
Follow all internal procedures, job aids, and HIPAA guidelines to protect patient privacy and data security.
Identify and report potential fraud, waste, and abuse.
Support training and development of new and existing team members as needed.
Assist leadership with special projects, process improvements, and operational initiatives
Minimum Qualifications:
Minimum of 6 months to a year of prior authorization or utilization management experience
Active, unrestricted, pharmacist license
Bachelor’s or Doctor of Pharmacy degree
Minimum of 2 years of pharmacy practice experience
Experience in managed care or pharmacy benefit management (PBM)
Strong communication, writing, and organizational skills
Ability to manage multiple priorities in a high-volume, metric-driven environment
Availability to work after hours, weekends, and holidays on a rotating schedule
Preferred Qualifications:
Call center experience
This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.
Manager, Client Experience Resolution & Optimization (CERO)
Position Summary
The Manager of Client Experience Resolution & Optimization (CERO) leads the intake, triage, and resolution process for client-impacting issues within Client Services. This role establishes governance for intake workflows, ensures issues are accurately validated and routed, and drives consistency in how Client Services manages and resolves operational challenges. The Manager partners across the organization to streamline processes, reduce manual work, and improve end-to-end client experience, while providing coaching for the CERO Analyst.
Position Responsibilities:
Build and manage a standardized intake and routing process for Client Services issues.
Govern issue of triage, prioritization, and cross-functional coordination.
Serve as the primary point of contact for inquiries related to intake, validation, and routing.
Develop and maintain SOPs, workflows, and documentation supporting Client Services operations.
Establish and monitor high‑level performance indicators (e.g., intake volumes, turnaround times, quality measures) in partnership with internal analytics teams.
Lead continuous improvement initiatives aimed at simplifying workflows and reducing recurring issues.
Partner with functional teams to identify process gaps and support implementation of improvements.
Coach, mentor, and support ongoing development of the CERO Analyst.
Required Qualifications:
Bachelor’s degree is required
5+ years of experience in client services, operations, or workflow/process management.
Demonstrated success in establishing governance structures or managing intake of workflows.
Strong collaboration, communication, and organizational skills.
Ability to manage complexity and problem-solve in a fast-paced environment.
Utilization Management Appeals Technician (Temp to Hire)
Position Summary:
Responsible for taking incoming requests for first, second level and external appeals while ensuring high level of customer service and maximizing productivity. Work with appeals team for multiple lines of business such as Commercial, Exchange and Medicare, ensuring the proper submission of appeals for review by pharmacist and medical directors.
Position Responsibilities:
Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements.
Remain current on all communications and updated processes relayed through multiple communication channels and apply to daily responsibilities.
Follow all internal Standard Operating Procedures and adhere to HIPAA guidelines and policies.
Review all cases received, to verify if case meets qualifications for appeal review.
Performs triple check to ensure quality reviews and handling in accordance with policies and procedures.
Updates case types, sends appeal acknowledgements, and submits case information to independent review organizations.
Communicate effectively with appeal pharmacists regarding internal and external appeals.
Make verbal outreach attempts to obtain necessary information for case review and record accurate information obtained on the call.
Exhibit excellent phone and communication skills while providing complete and accurate information to members and providers.
Performs all other related duties as assigned
Minimum Qualifications:
1 + years’ experience working as a certified pharmacy technician in a managed care or PBM setting required.
Active, unrestricted certified pharmacist technician license required.
Excellent organization details and strong detail orientation.
Strong oral and written communication skills.
Ability to work independently with minimal supervision, stay productive in a remote, high-volume, metric driven environment with shifting priorities.
Ability to work 12pm-9pm EST hours
Preferred Qualifications:
Experience working with commercial and medicare appeals preferred
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