in Tampa
, FL
Reference: 19-02335


  • Reviews Medicare and Medicaid members’ claims history to ensure clinical appropriateness and optimum care while performing utilization management activities including dose optimization and formulary management for prior authorizations and coverage determination requests
  • Monitors quality of prior authorization and coverage determination requests for our Medicare and Medicaid lines of business
  • Monitors pharmacy performance to ensure all regulatory state and federal contractual requirements are met
  • Develops and maintains medication protocols and decision tools
  • Develops policies and procedures, present medication reviews at Pharmacy & Therapeutic Committee meetings and provides a source of drug information to the client’s associates, providers, and its members

Essential Functions:

  • Reviews Medicare and Medicaid prior authorizations and coverage determination requests to ensure clinical appropriateness and optimization of care
  • Ensures associates handle prior authorization/coverage determination requests within all federal and state regulatory compliance time frames
  • Ensures associates apply departmental policies and procedures, clinical criteria justifications, and defined roles and responsibilities to prior authorization/coverage determination decisions and/or during inbound or outbound phone calls
  • Reviews pharmacy claims data to identify possible clinical savings opportunities
  • Presents medication reviews at Pharmacy and Therapeutics Committee meetings
  • Develops and maintains medication protocols and decision tools
  • Develops departmental policies and procedures in conjunction with all state, federal, and contractual requirements
  • Performs special duties as assigned


  • A Bachelor’s Degree in Pharmacy
  • A Pharm D preferred


  • Previous clinical pharmacy support for pharmacy, DM programs, quality and UM
  • Exposure to managed care preferred


  • Licensed pharmacist in state of operation

Special Skills:

  • Independence with regards to clinical discussions and evaluations
  • Ability to use pharmaceutical and medical reference literature to provide drug information to the health plan, patients and prescribers

Technical Skills/Requirements:

  • Use of Word, Excel and PowerPoint