Utilization Management Clinical Pharmacist 1

Job Description

Job Description

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 I is a volume-driven, production-focused role centered entirely on the clinical adjudication of initial prior authorization (PA) requests. Operating in a fast-paced, virtual environment, this individual will critically evaluate medical necessity and accurately apply plan criteria, regulatory guidelines, and evidence-based comparative effectiveness data. The Clinical Pharmacist I ensures timely, accurate determinations while providing essential foundational support to the Pharmacy Support Specialist (PSS) team.

Essential Functions

  Clinical Case Adjudication & Production  

• High-Volume Case Review: Evaluate and adjudicate initial prior authorization (PA) requests efficiently, ensuring strict accuracy against established clinical criteria and protocols.
• Criteria Application: Precisely apply plan-specific criteria, evidence-based clinical guidelines, comparative effectiveness research data, and strict regulatory standards to deliver timely determinations.
• Database Navigation: Leverage specialized clinical drug databases to analyze drug indications, dosage limits, and distinct clinical parameters during the review process.

  Communication & Interdisciplinary Support  

• Empathetic Communication: Articulate approval and denial decisions clearly, professionally, and empathetically through structured documentation and direct communication with members and healthcare providers.
• PSS Coordination: Serve as a reliable clinical resource for the Pharmacy Support Specialist (PSS) team, providing clear guidance and clinical interpretations for complex inquiries from prescribers, pharmacies, and members.
• Knowledge Maintenance: Maintain up-to-date, comprehensive knowledge of modern managed care trends, evolving comparative effectiveness data, clinical guidelines, and utilization management workflows.

Operational Excellence

• Workflow Optimization: Actively support and contribute to continuous process improvement initiatives to streamline internal operational workflows, boost team efficiency, and optimize turnaround times (TAT).
• Team Alignment: Perform additional operational duties and tasks as required to support broader clinical team production goals.

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

Education & Licensure

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

Required Experience & Skills

• Clinical Acumen: Strong foundational clinical skills with a demonstrated ability to critically evaluate and apply complex clinical data to individual case reviews.
• Remote Productivity: Self-motivated, highly organized, and capable of maintaining high-volume production metrics while working effectively in a virtual/remote team environment.
• Process-Oriented: A meticulous eye for detail with a proven track record of precisely following established health plan criteria, compliance parameters, and protocols.
• Communication Excellence: Exceptional written and verbal communication skills paired with a strong customer-service mindset.

Preferred Qualifications 

• Managed Care Exposure: Prior experience working in managed care, utilization management, or pharmacy benefit management (PBM) operations.
• Drug Data Systems: Strong working knowledge and familiarity with clinical drug databases (e.g., Medi-Span, First Databank) to seamlessly navigate drug files.
• Regulatory Compliance: Direct familiarity with NCQA, URAC, or CMS quality guidelines and compliance timelines.

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