Specialty UM Pharmacist

Pharmacist - Utilization Management

Curative is building the future of health insurance with a first-of-its-kind employer-based plan designed to remove financial barriers and make care truly accessible: one monthly premium with $0 copays and $0 deductibles. Backed by our recent $150M in Series B funding and valuation at $1.275B, Curative is scaling rapidly and investing in AI-powered service, deeper member engagement, and a smart network designed for today's workforce.

Our north star guides everything we do: healthcare only works when people can actually use it. That belief drives every decision we make: from how we design our plan, support our members, to how we collaborate as a team.

If you want to do meaningful work with a team that moves fast, experiments boldly, and cares deeply, Curative is the place to do it. We're growing fast and looking for teammates who want to help transform health insurance for the better.

Essential Duties and Responsibilities

• Performs prior authorization reviews and coverage determinations for medications covered under the medical benefit, including provider-administered therapies billed through J-codes, Q-codes, and other HCPCS codes
• Evaluates medical necessity, site-of-care appropriateness, dosing, diagnosis, and adherence to evidence-based clinical criteria for specialty drug requests
• Manages all levels of clinical review from Adverse Determination, Appeals and IRO
• Supports and manages utilization management operations across medical and pharmacy benefits to ensure alignment with health plan goals
• Writes, reviews, and updates PA guidelines to support both pharmacy and medical benefit strategies
• Acts as a clinical resource and liaison between medical and pharmacy teams, providing training and education to internal and external stakeholders as needed
• Meets assigned metrics and TAT as defined by regulatory requirements within state or lines of business
• Collaborate with Medical Directors and other interdepartmental staff to communicate utilization management strategies and clinical programs or initiatives
• Reviews and resolves complaints made by members and providers regarding Prior Authorizations
• Participates in support of the Pharmacy and Therapeutics Meeting to review and keep current on the drug formulary
• Performs appropriate literature and clinical research
• Knowledge of utilizing LexiComp, Micromedex, UpToDate, National guidelines, NCCN, etc.
• Collaborate to create clear communication to members and/or providers on prior authorization determinations
• Supports cross-functional collaboration efforts to bridge pharmacy and medical benefit operations, ensuring seamless integration and clinical alignment
• Work in partnership with utilization management staff to assist in the implementation of utilization management programs
• Works in collaboration with Pharmacy UM Director to help with workflows and operational efficiencies
• Evaluate opportunities for operational or process improvements
• Support and manage other related health plan operations
• Work adhering to US regulatory and Quality System requirements (21 CFR 820, etc.)
• This position assumes and performs other duties as assigned.
• Work hours are Monday-Friday and some Saturdays.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions:

• Possess strong analytical skills and detail oriented
• Ability to work independently with minimal supervision
• Understanding of claims processing and claims edits
• Intermediate level proficiency with MS Office applications- Word, Power Point, Excel, and Access
• Intermediate to advanced pharmacy drug recognition
• Ability to work in a dynamic and fast-paced environment

Required

• 2 years of experience with specialty medications or prior authorization
• 1 year of experience with PBM or Managed Care setting

Preferred Qualifications

• 3 years as practicing pharmacist or 1 year as PGY-1 resident
• 2 years experience in a Managed Care Setting
• Knowledge of Medispan or First Data Bank and drug classification system
• BCPS or CSP certification
• Experience with medical drug policies, utilization management programs, or health plan operations
• Experience reviewing oncology, immunology, rheumatology, gastroenterology, neurology, or other specialty medications
• Knowledge of HCPCS coding, medical claims adjudication, and specialty drug reimbursement methodologies

Education and/or Experience

• Doctor of Pharmacy (Pharm D) degree.

Certificates, Licenses, Registrations

• Must possess an active RPh license within state of residence.

Work Environment

• While performing the duties of this Job, the employee is regularly required to sit; use hands to handle or feel; talk; and hear.
• For this position the percentage of expected Travel is: 0%-10% of the time

Perks & Benefits

• Curative Health Plan (100% employer-covered medical premiums for you and 50% coverage for dependents on the base plan.)
• $0 copays and $0 deductibles (with completion of our Baseline Visit)
• Preventive and primary care built in
• Mental health support (Rula, Televero, Two Chairs, Recovery Unplugged)
• One-on-one care navigation
• Chronic condition programs (diabetes, weight, hypertension)
• Maternity and family planning support
• 24/7/365 Curative Telehealth
• Pharmacy benefits
• Comprehensive dental and vision coverage
• Employer-provided life and disability coverage with additional supplemental options
• Flexible spending accounts
• Flexible work options: remote and in-person opportunities
• Generous PTO policy plus 11 paid annual company holidays
• 401K for full-time employees
• Generous Up to 8–12 weeks paid parental leave, based on role eligibility.