Utilization Management Clinical Pharmacist

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

As a Utilization Management Clinical Pharmacist, you will join TruDataRx’s dynamic team of physicians, pharmacists, and scientists. We are seeking experienced managed care pharmacists who excel at applying data-driven insights and evidence-based guidelines to clinically-based determinations of coverage. In this role, you will utilize comparative effectiveness research according to the TruDataRx Clinical Process to ensure members receive clinically appropriate, cost-effective medications. Operating in a fast-paced, virtual environment, you will be pivotal in maintaining compliance with strict quality, regulatory, and turnaround standards.

Essential Functions

Clinical Review & Adjudication

• Evaluate and adjudicate prior authorization (PA) requests for accuracy and against established clinical criteria.
• Evaluate and adjudicate appeal requests for clinical appropriateness and medical necessity.
• Apply plan criteria, evidence-based guidelines (including comparative effectiveness data), and regulatory standards to deliver timely determinations in a fast-paced environment.
• Leverage clinical drug databases to accurately review drug data, indications, and clinical parameters during the adjudication process.

Communication & Consultation

• Communicate approval and denial decisions clearly, professionally, and empathetically to providers and members.
• Provide clinical support and guidance to Pharmacy Support Specialists handling complex inquiries from prescribers, pharmacies, and members.
• Collaborate with prescribers and outreach to members to resolve medication concerns, balancing compassionate care with operational accountability.

Operational Excellence

• Support process improvement initiatives to streamline operational workflows, boost efficiency, and optimize turnaround times.
• Maintain up-to-date knowledge of relevant managed care trends, comparative effectiveness research, clinical guidelines, and utilization management workflows.

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

• Managed Care Experience: Prior experience in managed care, utilization management, or pharmacy benefit management (PBM) operations.
• Clinical Acumen: Strong clinical skills with the ability to critically evaluate and apply complex clinical data to individual case reviews.
• Remote Productivity: Self-motivated, highly organized, and capable of working effectively both independently and collaboratively in a virtual environment.
• Process-Oriented: A meticulous eye for detail with a proven ability to precisely follow and apply established plan criteria and protocols.
• Communication Excellence: Exceptional written and verbal communication skills, with a strong customer-service mindset.

Preferred Qualifications (A Big Plus)

• Clinical Drug Databases: Strong working knowledge and familiarity with clinical drug databases (e.g., Medi-Span, First Databank) to navigate drug files and clinical parameters.
• Accreditation & Regulatory Knowledge: Direct familiarity with NCQA, URAC, or CMS 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