Remote Pharmacy Review Physician - 249027

Must have one of the below

FL License

NC License

IMLC

This organization is a technology-driven health insurance company built on a full-stack platform with a strong focus on member-centered care. Founded in 2012, it was created to deliver the kind of health insurance experience people would want for themselves—one that feels supportive, accessible, and clinically grounded.

About the Role

You will evaluate the clinical appropriateness of inpatient, outpatient, and pharmacy services , with a strong emphasis on medication utilization, by reviewing clinical information and applying evidence-based guidelines.

Hours: 8:00 AM – 5:00 PM (local time zone)

Call Rotation: One weekend every 16 weeks

You will report to the Associate Medical Director, Utilization Management.

Key Responsibilities

• Conduct timely utilization reviews for medical and pharmacy services in alignment with established quality standards
• Evaluate medication requests for appropriateness, safety, and efficacy using evidence-based criteria, formulary guidelines, and clinical judgment
• Make coverage determinations for pharmacy and medical benefit drugs, including prior authorizations and exceptions
• Clearly and accurately document decisions and communications in workflow systems using appropriate templates
• Ensure documentation is clear and accessible for members and providers
• Meet required turnaround times for all reviews
• Review escalated or complex cases as needed, including high-cost or specialty medications
• Participate in peer-to-peer discussions with treating providers to clarify clinical information and explain review outcomes, including alternative treatment options when appropriate
• Maintain compliance with all applicable laws, regulations, and accreditation standards
• Perform other duties as assigned

Requirements

• MD/DO
• Active, unrestricted license in Florida or North Carolina and/or eligibility for or participation in the Interstate Medical Licensure Compact (IMLC) (for physicians)
• Minimum of 6 years of clinical experience (physician or pharmacist)
• At least 1 year of utilization management or pharmacy utilization review experience within a managed care, PBM, or health insurance setting

Preferred Qualifications

• Licensure in multiple states
• Board certification (for physicians) or relevant pharmacy certifications (e.g., BCPS, BCACP)
• Experience with formulary management, prior authorization, or specialty pharmacy reviews
• Experience in managed care, PBM, or health plan environments
• Willingness to obtain additional state licenses as needed, with employer support