Specialty UM Pharmacist

Curative HR LLC•Austin, TX

3d•$130,000 - $150,000•Remote

About The Position

This role is primarily responsible for utilization management activities related to specialty medications covered under the medical benefit, including provider-administered drugs billed under J-codes, Q-codes, and other HCPCS codes. The pharmacist will perform prior authorization reviews to ensure appropriate, evidence-based use of high-cost specialty therapies. The role will also support medical drug policy development, utilization management strategy, provider education, formulary management, Pharmacy & Therapeutics (P&T) Committee activities, and cross-functional initiatives involving both medical and pharmacy benefits. As Curative continues to grow, responsibilities may evolve to support organizational and business needs. This is a REMOTE Position with RPh Licensure required in the state of residence.

Requirements

Possess strong analytical skills and detail oriented
Ability to work independently with minimal supervision
Understanding of claims processing and claims edits
Intermediate level proficiency with MS Office applications- Word, Power Point, Excel, and Access
Intermediate to advanced pharmacy drug recognition
Ability to work in a dynamic and fast-paced environment
2 years of experience with specialty medications or prior authorization
1 year of experience with PBM or Managed Care setting
Doctor of Pharmacy (Pharm D) degree.
Must possess an active RPh license within state of residence.

Nice To Haves

3 years as practicing pharmacist or 1 year as PGY-1 resident
2 years experience in a Managed Care Setting
Knowledge of Medispan or First Data Bank and drug classification system
BCPS or CSP certification
Experience with medical drug policies, utilization management programs, or health plan operations
Experience reviewing oncology, immunology, rheumatology, gastroenterology, neurology, or other specialty medications
Knowledge of HCPCS coding, medical claims adjudication, and specialty drug reimbursement methodologies

Responsibilities

Performs prior authorization reviews and coverage determinations for medications covered under the medical benefit, including provider-administered therapies billed through J-codes, Q-codes, and other HCPCS codes
Evaluates medical necessity, site-of-care appropriateness, dosing, diagnosis, and adherence to evidence-based clinical criteria for specialty drug requests
Manages all levels of clinical review from Adverse Determination, Appeals and IRO
Supports and manages utilization management operations across medical and pharmacy benefits to ensure alignment with health plan goals
Writes, reviews, and updates PA guidelines to support both pharmacy and medical benefit strategies
Acts as a clinical resource and liaison between medical and pharmacy teams, providing training and education to internal and external stakeholders as needed
Meets assigned metrics and TAT as defined by regulatory requirements within state or lines of business
Collaborate with Medical Directors and other interdepartmental staff to communicate utilization management strategies and clinical programs or initiatives
Reviews and resolves complaints made by members and providers regarding Prior Authorizations
Participates in support of the Pharmacy and Therapeutics Meeting to review and keep current on the drug formulary
Performs appropriate literature and clinical research
Knowledge of utilizing LexiComp, Micromedex, UpToDate, National guidelines, NCCN, etc.
Collaborate to create clear communication to members and/or providers on prior authorization determinations
Supports cross-functional collaboration efforts to bridge pharmacy and medical benefit operations, ensuring seamless integration and clinical alignment
Work in partnership with utilization management staff to assist in the implementation of utilization management programs
Works in collaboration with Pharmacy UM Director to help with workflows and operational efficiencies
Evaluate opportunities for operational or process improvements
Support and manage other related health plan operations
Work adhering to US regulatory and Quality System requirements (21 CFR 820, etc.)
This position assumes and performs other duties as assigned.
Work hours are Monday-Friday and some Saturdays.

Benefits

Curative Health Plan (100% employer-covered medical premiums for you and 50% coverage for dependents on the base plan.)
$0 copays and $0 deductibles (with completion of our Baseline Visit )
Preventive and primary care built in
Mental health support (Rula, Televero, Two Chairs, Recovery Unplugged)
One-on-one care navigation
Chronic condition programs (diabetes, weight, hypertension)
Maternity and family planning support
24/7/365 Curative Telehealth
Pharmacy benefits
Comprehensive dental and vision coverage
Employer-provided life and disability coverage with additional supplemental options
Flexible spending accounts
Flexible work options: remote and in-person opportunities
Generous PTO policy plus 11 paid annual company holidays
401K for full-time employees
Generous Up to 8–12 weeks paid parental leave, based on role eligibility.