Clinical Pharmacotherapy Specialist

2 days ago

Taguig, National Capital Region, Philippines beBeePharmaceutical Full time $90,000 - $120,000
Job Description:
The role of Utilization Review Pharmacist involves conducting clinical reviews of medication requests to determine medical necessity, appropriateness, and compliance with plan guidelines. This position requires collaboration with medical directors, case managers, and providers to ensure safe, cost-effective, and evidence-based pharmaceutical care for members.

Key Responsibilities:
  • Conduct prospective, concurrent, and retrospective utilization reviews for medications and pharmacy services.
  • Apply clinical criteria to make coverage determinations.
  • Review and process prior authorizations, step therapy, and quantity limit overrides.
  • Collaborate with physicians, nurses, and customer service teams on clinical determinations.
  • Document clinical decisions accurately within UR systems and according to regulatory requirements.
  • Support appeals and grievance processes by reviewing denied claims and providing clinical input.

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