Job Overview
Location
Remote
Job Type
Full-time
Category
Product Management
Date Posted
May 17, 2026
Full Job Description
đź“‹ Description
- • Perform drug utilization reviews for initial determinations and appeals across ASO clients, Medicare Advantage plans, and future lines of business, basing decisions on clinical evidence and supporting documentation.
- • Execute the operational workflow for all drug utilization management processes, ensuring timely and compliant completion of reviews aligned with accreditation and regulatory standards.
- • Serve as the primary subject matter expert for pharmacy utilization management, providing guidance and support to cross-functional teams on drug review policies and procedures.
- • Participate actively in the appeals process for pharmacy benefit determinations, responding to provider and client inquiries with clear, evidence-based justifications.
- • Collaborate with the Medical Director and Clinical Formulary team to evaluate specialty medications requiring specialty consults and make evidence-informed recommendations for formulary inclusion or restrictions.
- • Analyze monthly claims data to assess the effectiveness of current formulary and utilization management strategies, identifying trends and areas for operational improvement.
- • Identify and escalate operational or technical issues impacting drug utilization reviews to the Manager of Clinical Pharmacy and Director of Clinical and Technical Integration.
- • Assist in the development and refinement of internal policies related to drug utilization management, ensuring alignment with regulatory requirements and organizational goals.
- • Create and update training materials and clinical development tools to educate pharmacy staff and providers on utilization review decision-making criteria and processes.
- • Precept pharmacy residents and rotational pharmacy students, providing clinical supervision and feedback in the context of utilization management workflows.
- • Maintain strict confidentiality of patient and client data in accordance with HIPAA and other privacy regulations.
- • Work independently and proactively to research, resolve, and document complex drug review cases under time-sensitive conditions.
- • Communicate effectively with clients, providers, and internal stakeholders to resolve disputes regarding drug coverage determinations.
- • Demonstrate proficiency in Microsoft Office applications, particularly Excel and Access, for data analysis, reporting, and documentation tasks.
- • Adapt to a fast-paced, evolving environment while managing multiple priorities and meeting strict deadlines in a remote work setting.
- • Occasionally participate in offsite meetings requiring minimal travel.
🎯 Requirements
- • Current and unrestricted pharmacist license issued by state of residence
- • Three (3) years of clinical pharmacy experience
- • Two (2) years of managed care experience
- • Extensive working knowledge of Microsoft Excel and Access
- • Understanding of CMS regulations, HIPAA, and the regulatory environment for pharmacy benefits
- • Ability to work independently and handle confidential information in a remote setting
🏖️ Benefits
- • Remote work position
- • Exempt salaried role with standard 40-hour weekly schedule
- • Opportunity to work with a clinical pharmacy team supporting Medicare Advantage and ASO clients
- • Professional development through precepting pharmacy students and residents
Skills & Technologies
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About West Virginia University Hospitals, Inc.
West Virginia University Hospitals is the clinical enterprise of West Virginia University, operating a network of academic medical centers, community hospitals, and outpatient clinics across West Virginia. It provides tertiary and quaternary care, medical education, and research, anchored by J.W. Ruby Memorial Hospital in Morgantown. Services include cancer, heart, trauma, pediatrics, and behavioral health. The system serves as the state’s largest employer and leads rural health initiatives, telemedicine, and graduate medical training programs. Governance is through West Virginia University Health System, a tax-exempt, nonprofit subsidiary of the university.
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