Utilization Management Clinical Pharmacist II

Description

About TruDataRx

TruDataRx, Inc. uses objective clinical data to help clients improve the clinical efficacy and reduce the costs of pharmacy benefits for its members. We are independent from all players in the pharmaceutical manufacturing and distribution industries, enabling us to best serve our clients. We value the following characteristics in our team members:

• •Outward Mindset – foundation of our culture, which influences the right behaviors, that leads to results
• •Entrepreneurial – the ability to get things done with resources you don’t control
• •Humility – deep comfort in knowing when you don’t know and asking questions
• •Collaboration – we always give benefit of doubt that each person has something to contribute

Position Summary

The Clinical Pharmacist II is an advanced clinical role responsible for the evaluation and adjudication of complex drug coverage requests, second-level reviews, and clinical appeals. The Clinical Pharmacist II specializes in managing clinical escalations, interpreting ambiguous clinical data, and conducting high-touch Peer-to-Peer (P2P) reviews directly with prescribing physicians. This position requires exceptional telephonic communication skills, clinical negotiation capabilities, and the ability to articulate complex clinical rationales clearly and professionally to both providers and members.

Essential Functions

Appeals Adjudication & Complex Case Review

• •Clinical Appeals Evaluation: Evaluate, research, and adjudicate first- and second-level clinical appeals and highly complex drug coverage requests against established plan criteria and evidence-based clinical guidelines.
• •Comparative Effectiveness Synthesis: Utilize comprehensive comparative effectiveness data, medical literature, and patient-specific charts to determine medical necessity for non-formulary or specialized therapies.
• •Regulatory Compliance: Ensure all appeal determinations are completed within strict regulatory, client-specific, and accreditation compliance timelines.

Provider Escalations & Peer-to-Peer Reviews

• •Peer-to-Peer Consultation: Conduct direct, professional Peer-to-Peer telephonic reviews with prescribing physicians and advanced practice providers to discuss denial rationales, clinical alternatives, and documentation requirements.
• •High-Touch Conflict Resolution: Handle escalated, sensitive, or emotionally charged phone inquiries from members and providers, balancing clinical policy compliance with deep empathy and a customer-service mindset.
• •Comprehensive Documentation: Meticulously document all verbal discussions, clinical rationales, and final appeal determinations within the internal utilization management platform.

Interdisciplinary Mentorship & Workflow Support

• •Advanced Clinical Resource: Serve as a subject matter expert and escalation resource for Clinical Pharmacist I and Pharmacy Support Specialist (PSS) teams regarding complex clinical questions or ambiguous plan criteria.
• •Criteria & Policy Feedback: Actively identify trends in clinical appeals and provider pushback, providing structured feedback to the clinical leadership team to help optimize future formulary design and criteria documentation.

Other duties as required.*

*This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice.

Requirements

Requirements

Education & Licensure

• •Doctor of Pharmacy (PharmD) degree from an accredited institution.
• •Active, unrestricted pharmacist license in your state of residence.

Required Experience & Skills

• •Experience: Minimum of 1–2 years of direct experience in managed care, utilization management, or pharmacy benefit management (PBM) operations, with a strong preference for candidates who have specifically handled clinical appeals.
• •Telephonic Communication Excellence: Exceptional verbal communication and active listening skills are strictly required. The candidate must possess a proven ability to confidently and professionally navigate complex clinical phone conversations with physicians and anxious members.
• •Clinical Negotiation & Acumen: Advanced analytical skills to critically evaluate complex medical literature and chart notes, translating technical clinical parameters into clear, logical, and defensible rationales.
• •Remote Productivity: Highly organized, self-motivated, and capable of managing complex caseloads independently within a virtual team environment.

Preferred Qualifications

• •Specialty Pharmacy Insight: Familiarity with high-cost specialty medication classes, oncology pipelines, or rare disease therapeutics.
• •System Familiarity: Direct experience working within specialized PBM processing architectures, external portal structures, and clinical drug databases (e.g., Medi-Span, First Databank).
• •Accreditation Guidelines: Deep working knowledge of URAC, NCQA, and CMS appeal compliance standards.

Company Standard Requirements:

• •Ability to work well with others in a collaborative environment
• •Ability to get things done with resources you don’t control
• •Willingness to admit you don’t know and ask for help
• •Exhibit constant curiosity and a drive to problem solve
• •Exhibit desire to learn and grow on a continuous basis