Pharmacy Clinical Review Specialist- Remote

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Pharmacy Clinical Review Specialist- Remote Job ID: 8219015248 Status: Full-Time Regular/Temporary: Regular Shift: Day Job Work Arrangement: Remote Facility: UPMC Health Plan Department: PHARMACY SRVCS Union Position: No Salary Range: $ 20.0-30.55 USD APPLY NOW SAVE JOB The Clinical Review Specialist will oversee administrative and system processes that relate to pharmacy prior authorizations. Manage the first line clinical review of prior authorization requests on behalf of physicians and UPMC Health Plan members. Collaborate with clinicians regarding supporting medical documentation in accordance with formulary guidelines. Manage the quality review of requested prior authorizations. Schedule is 11:30am-8:00 pm, Monday-Friday with a Saturday rotation monthly. Training schedule will be 8:30am-5:00 pm Monday-Friday. Equipment will be provided. As this position is remote, please understand that we do have the ability to have staff report to and work from our primary location, US Steel Tower as well. Responsibilities: Provide excellent internal and external customer service maintaining a second requests for information and customer complaint goal of zero. Act as a conduit of information between the Pharmacy Service Representatives and the clinical staff Subject matter expert on formulary exceptions and prior authorization requirements/time frames according to line of business. Perform peer reviews of prior authorization requests. Maintain or exceed designated quality and production standards. Develop and maintain the pre-logic and clinical criteria in support of the prior authorization determination process. Interface with other departments and identify medical documentation in support of prior authorization requests. Complete standard/expedited pharmacy coverage determinations according to departmental/government guidelines. Report and respond to escalate issues and concerns in a within twenty-four hours. Process requests and inquiries in accordance with all governing regulatory agencies including but not limited to CMS, DPW, DHHS, HCFA, DOI and NCQA laws and standards. Qualifications: HS diploma and pharmacy claims, pharmacy tech, and/or other related experience in a physician practice, ancillary provider, or other relevant healthcare setting required. Competent in pharmacy claims process operating system. Excellent knowledge in UPMC’s Health Plan internal department functions. Excellent knowledge of medical terminology, coordination of benefits, complaints and grievance guidelines and prescription drug utilization management requirements. Thorough knowledge in MS Office and PC skills required. Organizational, analytical, interpersonal, and communication skills. Ability to prioritize and perform multiple tasks while maintaining designated production and quality standards. Staff is required to work scheduled overtime and be available for emergency overtime as business needs dictate. Staff is required to work a temporary, alternative schedule or shift as requested by supervisor. Licensure, Certifications, and Clearances: Act 34 UPMC is an Equal Opportunity Employer/Disability/Veteran APPLY NOW SAVE JOB SHARE JOB CAREER GROWTH Grow Your Nursing Career Spanning over 20 clinical specialties and more than 50 unique nursing roles, every nurse at UPMC can achieve and advance their goals with the My Nursing Career Ladder. Whether you’re looking to progress to an elevated role or continue your education, UPMC equips nurses with the resources, feedback, leadership, and benefits to help you succeed and achieve your career goals. Here’s how a few nurses have grown their careers through the years at UPMC: Clyde C. Michelle B. Clyde C. Clyde C. As a Professional Staff Nurse, Expert at UPMC Muncy, Clyde is a great example of someone who has taken advantage of UPMC’s My Nursing Career Ladder to grow his career while remaining in the same hospital location. Clyde’s Career Journey: ⦁ 2017: Professional Staff Nurse – UPMC Muncy ⦁ 2021: Sr. Professional Staff Nurse – UPMC Muncy ⦁ 2022: Sr. Professional Staff Nurse II – UPMC Muncy ⦁ 2022-present: Professional Staff Nurse, Expert – UPMC Muncy Michelle B. Michelle B. In her current role as a Professional Staff Nurse, Expert at UPMC Presbyterian, Michelle cares for patients with chronic and ongoing health issues as part of a Medical-Surgical unit. Michelle enjoys the daily change that Med-Surg nursing brings, and has found a career path that is interesting, meaningful, and full of opportunity. Michelle’s Career Journey: ⦁ 2019: Staff Nurse – UPMC Presbyterian ⦁ 2020: Professional Staff Nurse – UPMC Presbyterian ⦁ 2021: Professional Staff Nurse, BSN – UPMC Presbyterian ⦁ 2021: Sr. Professional Staff Nurse, BSN – UPMC Presbyterian ⦁ 2022: Sr. Professional Staff Nurse II, BSN – UPMC Presbyterian ⦁ 2023: Professional Staff Nurse, BSN, Expert – UPMC Presbyterian INSURANCE SERVICES DIVISION OF UPMC Advance Your Future A career with UPMC means more than just caring for patients – when you’re a part of UPMC Insurance Services Division, it means caring for more than four million insurance members, too. UPMC Insurance Services Division offers a full range of health insurance products and services to our network across the country, providing peace of mind, better health, and financial security to our members, along with limitless career opportunities and a rewarding mission to those on our team. About Us Opportunities on Our Team Recognized for Excellence Jump-Start Your Career About Us About UPMC Insurance Services Division As an integrated health care provider-insurer, UPMC goes beyond patient care to provide insurance products and services to millions of members. Our team partners with UPMC and community network providers to deliver knowledge and expertise that provides the highest quality care at the most affordable price, supporting our members through service, communication, and more. Fast Facts: We provide insurance products and services to over more than four million members. UPMC’s Insurance Services Division offers a full range of health insurance options including UPMC Health Plan, Workpartners, UPMC for Life , UPMC for You , UPMC for Kids , UPMC Community HealthChoices, and Community Care Behavioral Health. UPMC Health Plan is among the nation’s fastest-growing health plans. Opportunities on Our Team Opportunities on Our Team We’ve got a job that’s just right for you! UPMC Insurance Services Division team offers a vast array of career paths and opportunities , from career areas like customer service, data analytics, and information technology and even patient care roles like social work, nursing, and care management. Whether in non-clinical or patient-facing roles, our team impacts patients and members by providing quality experiences before, during, and after their care, building relationships in a unique and meaningful way. Search Jobs Recognized for Excellence Recognized for Excellence Be a part of an award-winning team! UPMC Insurance Services Division has been recognized for outstanding care and service with awards that include: U.S. News and World Report named UPMC for Life a “Best Insurance Company for Medicare Advantage” in Pennsylvania for 2024. The Human Rights Campaign Foundation has named UPMC Health Plan an “Equality 100 Leader in LGBTQ+ Workplace Inclusion” for 2023–2024. UPMC for Life ranked #1 in Customer Satisfaction* among Medicare Advantage Plans in Pennsylvania by J.D. Power. The Ethisphere Institute named UPMC as one of the World’s Most Ethical Companies for the sixth consecutive year. *Results are based on award-eligible plans in Pennsylvania by J.D. Power. For J.D. Power 2024 award information visit, jdpower.com/awards . Jump-Start Your Career Jump-Start Your Career Looking to launch a career with longevity and opportunity? With countless entry-level opportunities for recent graduates, along with tools and resources that empower you as you learn and grow, UPMC Insurance Services Division is the perfect place to get a career started. Interested in taking your career to new heights? Our career paths and advancement opportunities will provide you with chances to achieve your goals at every step. Search Jobs BENEFITS AND LIFE AT UPMC Why Work Here We know that you have many options when choosing where to build your career. So why choose UPMC? We can think of a few reasons. Work-Life Balance Finding the ideal balance to manage the important elements in your life. Development & Opportunities Enhancing your career through continued learning opportunities and/or advancement. Compensation Receiving competitive pay for the work that you do – base pay, merit, and premium pay. Performance & Recognition Rewarding performance that supports the goals and mission of UPMC. Benefits Providing assistance and security to meet the current and future needs of you and your family. Work-Life Balance Finding the ideal balance to manage the important elements in your life. Development & Opportunities Enhancing your career through continued learning opportunities and/or advancement. Compensation Receiving competitive pay for the work that you do – base pay, merit, and premium pay. Performance & Recognition Rewarding performance that supports the goals and mission of UPMC. Benefits Providing assistance and security to meet the current and future needs of you and your family. Benefits that Matter to You We’re committed to providing benefits that meet your needs and support your well-being in all areas of life. Earn over 5 weeks of paid time off every year Affordable medical, dental & vision coverage Student loan assistance and tuition reimbursement options Earn up to 8% of your eligible pay in retirement contributions from UPMC Employer-paid life insurance Benefits that Matter to You We’re committed to providing benefits that meet your needs and support your well-being in all areas of life. Earn over 5 weeks of paid time off every year Affordable medical, dental & vision coverage Student loan assistance and tuition reimbursement options Earn up to 8% of your eligible pay in retirement contributions from UPMC Employer-paid life insurance Benefits that Matter to You We’re committed to providing our employees with benefits that meet their needs and support their well-being in all areas of life. Earn over 5 weeks of paid time off every year Affordable medical, dental & vision coverage Student loan assistance and tuition reimbursement options Earn up to 8% of your eligible pay in retirement contributions from UPMC Employer-paid life insurance Support for You – and Your Family Your career doesn’t impact just you, but the people you care about, too. We’re making sure your career works for the whole family. Two weeks of paid parental leave Family planning resources Tuition assistance for dependents Comprehensive health care for dependents Emergency child and elder care options Flexible work arrangements Support for You – and Your Family Your career doesn’t impact just you, but the people you care about, too. We’re making sure your career works for the whole family. Two weeks of paid parental leave Family planning resources Tuition assistance for dependents Comprehensive health care for dependents Emergency child and elder care options Flexible work arrangements Support for You – and Your Family Your career doesn’t impact just you, but the people you care about, too. We’re making sure your career works for the whole family. Flexibility to choose the shifts and work arrangements that work best for your lifestyle Two weeks of paid parental leave Family planning resources Comprehensive health care for dependents Emergency child and elder care options A Culture That Cares At UPMC, you can find a home among people who share your passions and care about who you are. Employee resource groups Awards for champions of dignity & respect Center for Workplace Culture and Engagement Programs for veteran engagement A Culture That Cares At UPMC, you can find a home among people who share your passions and care about who you are. Employee resource groups Awards for champions of dignity & respect Center for Workplace Culture and Engagement Programs for veteran engagement A Culture That Cares UPMC is a place where you can find a home, no matter your gender, race, sexual orientation, age, or culture, and where you can meet people who share your passions and care about you. Employee resource groups Awards for champions of dignity & respect Center for Workplace Culture and Engagement Programs for Veteran Engagement Tools to Reach Your Potential Once you become a member of our team, the journey doesn’t stop there. UPMC is committed to supporting your growth and helping you build the career of your dreams. Up to $6,000 of annual tuition assistance Ongoing learning via LinkedIn Learning Accelerated career pathways for growth Robust instructor-led education and learning pathways Tools to Reach Your Potential Once you become a member of our team, the journey doesn’t stop there. UPMC is committed to supporting your growth and helping you build the career of your dreams. Up to $6,000 of annual tuition assistance Ongoing learning via LinkedIn Learning Accelerated career pathways for growth Robust instructor-led education and learning pathways Tools to Reach Your Potential Once you become a member of our team, the journey doesn’t stop there. UPMC is committed to supporting your growth and helping you build the career of your dreams. Unlimited educational possibilities, including no-cost BSN and MSN programs Robust career ladders for every nurse – no matter your specialty, location, or career stage Up to $6,000 of annual tuition assistance Ongoing learning opportunities Expansive Opportunity Where do you want to go with your career? Wherever it is, UPMC can take you there. 100,000 employees 40+ hospitals and 800+ doctors’ offices and outpatient sites Dozens of career ladders to climb International locations State-of-the-art technology Expansive Opportunity Where do you want to go with your career? Wherever it is, UPMC can take you there. 100,000 employees 40+ hospitals and 800+ doctors’ offices and outpatient sites Dozens of career ladders to climb International locations State-of-the-art technology Expansive Opportunity Where do you want to go with your career? Wherever it is, UPMC can take you there. 100,000 employees 40+ hospitals and 800+ doctors’ offices and outpatient sites International locations State of-the-art technology LEARN MORE ABOUT BENEFITS * Note: Benefits described may not be applicable to all staff. Read More about Nursing at UPMC Never Too Late: Kendra’s UPMC Journey After working as a nursing assistant for 16 years, Kendra took the leap to go back to nursing school and become an RN. LEARN MORE Med-Surg Nursing in 4 Words: UPMC Nurses Share We asked our nurses to shed some light on what Med-Surg nursing means to them. Get to know Med-Surg nursing – in four words – from UPMC nurses! LEARN MORE Where Passion Meets Purpose: Leah’s UPMC Story Starting her career in Environmental Services, Leah shares how she fell in love with health care and became a nurse. LEARN MORE Read More about UPMC Insurance Services Division Why Data Analytics Matter to UPMC’s Mission In UPMC Insurance Services Division, analysts work to understand, innovate, and improve the products and services UPMC provides. LEARN MORE The Game of Life is About More Than Winning: Eddie’s UPMC Outlook Eddie S. shares how his passion for football, fishing, and friendship shapes his life and his career with UPMC Health Plan. LEARN MORE From the U.S. Army to UPMC Health Plan We asked our nurses to shed some light on what Med-Surg nursing means to them. Get to know Med-Surg nursing – in four words – from UPMC nurses! LEARN MORE Similar Jobs Summer Associate - Information Technology Internship Other Hybrid Posted: 1 days ago View Job Pharmacy Analyst, 340B Other Remote Posted: 1 days ago View Job Administrative Liaison UPP- Anesthesiology and Perioperative Medicine Other Hybrid Posted: 2 days ago View Job Similar Jobs Business Analyst (Hybrid)- Must be located in Pennsylvania! 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