Clinical Pharmacy Specialist (Remote)- Prior Authorization Team

UPMC•Pittsburgh, PA

5d•Remote

About The Position

UPMC Health Plan is hiring a full-time Clinical Pharmacy Specialist to support the Prior Authorization Team within the Pharmacy Services department. This is a work-from-home position with daylight hours between 8:00 a.m. and 5:00 p.m. EST. The pharmacist must be licensed in Pennsylvania or eligible for licensure by examination or reciprocity. The Clinical Pharmacy Specialist provides clinical pharmacy expertise for the development, implementation, and management of the pharmacy benefit. The role supports pharmacy utilization management and member care through medication prior authorization and appeals processes. Services must comply with state and federal regulations, including NCQA and CMS standards, and uphold UPMC Health Plan and Pharmacy Department policies and procedures. Candidates should demonstrate professionalism and commitment to UPMC Health Plan goals and objectives. The employee must be legally authorized to work in the United States without requiring current or future employment visa sponsorship. UPMC does not participate in STEM OPT.

Requirements

Bachelor of Science in Pharmacy and/or Doctor of Pharmacy degree (Pharm.D.) from an accredited U.S. School of Pharmacy.
Registration as a registered pharmacist (RPh) in the Commonwealth of Pennsylvania, or eligibility for licensure by examination or reciprocity.
Meet continuing education requirements for Pennsylvania pharmacist relicensure, including at least 30 hours of structured pharmaceutical education every two years.
Effective written and oral communication skills.
Strong analytical ability and organizational skills.
Computer literacy for pharmacy programming, word processing, and data management.
Legal authorization to work in the United States without requiring current or future employment visa sponsorship.

Nice To Haves

Experience in pharmacy benefit management, insurance, or managed care, and knowledge of therapeutic interventions and cost-containment programs.
Experience with claims adjudication, therapeutic substitution interventions, dose optimization, and other cost-containment programs.
Completion of a managed care residency or 1–3 years of managed care experience.

Responsibilities

Perform clinical reviews of prior authorization, step therapy, quantity limit, and other pharmacy utilization management requests in accordance with quality, timeliness, and efficiency standards.
Review pharmacy utilization management requests and determine approval or denial against standard clinical criteria and regulatory-approved policies.
Participate in a clinical call queue, responding to internal and external stakeholder inquiries about the exception process in a timely, accurate, and professional manner.
Participate in the pharmacy appeals process by reviewing denied cases and representing the committee at fair hearings.
Participate in other operational initiatives as needed.
Foster and maintain collaborative relationships with internal and external customers.
Perform duties independently, reliably, efficiently, accurately, and professionally while supporting a virtual team.
Research drugs and disease states for complex utilization management reviews and other responsibilities.
Maintain a home office setup that protects client and patient confidentiality.
Maintain a foundational understanding of Pennsylvania DHS, CMS, Pennsylvania Insurance Department, and NCQA requirements relevant to clinical operations and regulatory compliance.
Participate in meetings, committees, and work groups as assigned.
Mentor students, residents, and other pharmacists, if applicable.