Clinical Pharmacist Utilization Management

UnitedHealth Group
April 1, 2021
San Antonio, TX
Job Type


Do you have compassion and a passion to help others? Transforming healthcare and millions of lives as a result starts with the values you embrace and the passion you bring to achieve your life’s best work.(sm)

Under general supervision of the UM Director of Clinical Pharmacy, the UM Clinical Pharmacist is responsible for completing prior authorization functions as needed for WellMed Managed Care Patients. This position will also work with UM nurses as a Clinical Pharmacist and the Medical management P&T Committee. The Clinical Pharmacist is also responsible to follow processes to improve patient care, outcomes, and quality improvement metrics related to CMS HEDIS / Star ratings.

This pharmacist will primarily be conducting prior authorization reviews on Part B specialty medications and Oncology medications; assist with criteria development and preferably, should have a working knowledge of Medicare rules and regulations.

Hours will fall between 7am and 7pm and will be rotating Saturday shift either a 6am-3pm or 8-5pm shift. Currently, pharmacists are rotating every 3rd Saturday. Staff will also rotate working on holidays, if needed.

Primary Responsibilities:

  • Provide timely review for WellMed members by processing prior authorization and medical necessity requests for specialty CMS part B medications
  • Review specialty medication prior authorization requests (i.e. biopharmaceuticals) according to established treatment protocols, clinical criteria and member benefits. and make determinations within the defined turnaround times and meet regulatory requirements
  • Knowledgeable of current and emerging clinical trends
  • Active participation in various clinical departmental meetings and forums to improve clinical programs, enhance processes, and share clinical information
  • Continuously look for ways to streamline and improve workflow
  • Assist with user acceptance testing for new clinical programs and system enhancements
  • Ensure and evaluate quality controls and implement opportunities for performance improvement in pharmacy practice specific to specialty pharmacy
  • Serves as a clinical resource and consultant in all areas of pharmacy and medication management
  • Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews
  • Supports medical management and pharmacy quality initiatives
  • Follow all policies and procedures related to job

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

  • Doctor of Pharmacy degree
  • Current pharmacist license to practice in the applicable state or the ability to provide proof of licensure within 90 days from date of employment
  • 2+ years of experience as a Prior Authorization Pharmacist or Clinical Pharmacist
  • Analytical and PC operation skills
  • Experience working with provider relations, working within various payor environments, and risk management
  • Ability to travel as necessary
  • Employees are required to screen for symptoms using the ProtectWell mobile app, Interactive VoiceResponse (i.e., entering your symptoms via phone system) or a similar UnitedHealth Group approved symptom screener prior to entering the work site each day, in order to keep our work sites safe. Employees must comply with any state and local masking orders. In addition, when in a UnitedHealth Group building, employees are expected to wear a mask in areas where physical distancing cannot be attained
  • You will be asked to perform this role in an office setting or other company location

Preferred Qualifications:

  • Fluent in Spanish language
  • Board certification by the Board of Pharmacy Specialties (BPS)
  • Certified Geriatric Pharmacist
  • Certification in Medication Therapy Management (MTM)
  • Experience with Medicare guidelines
  • Excellent written and verbal communication skills
  • Excellent relationship building skills
  • Planning and organizational skills to demonstrate leadership and initiative
  • Excellent interpersonal skills
  • Ability to work independently, as well as a member of a team

Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 380,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
Job Keywords: Oncology, Speciality Pharmacy, Clinical Pharmacist Utilization Management, San Antonio, TX, Texas
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