3539-Utilization Management (UM) Pharmacist Reviewer

About the Role

We are seeking a Utilization Management (UM) Pharmacist Reviewer to lead the clinical validation and translation of payer policies into our AI-powered prior authorization workflows. This role owns the process of ensuring our solution accurately represents payer intent, medical necessity criteria, and evidence-based standards for pharmacy benefits.

The ideal candidate brings deep expertise in utilization management and formulary review, coupled with the ability to transform complex clinical policies into structured, logical decision trees. This role combines clinical judgment, operational insight, and technical collaboration to ensure every automated authorization recommendation is clinically sound, compliant, and scalable across specialties.

This position is central to the success of our AI-powered prior authorization platform. The UM Pharmacist Reviewer leads the transformation of payer and evidence-based policies into decision logic that drives automated medical necessity evaluations. Their ownership ensures each workflow reflects clinical accuracy, regulatory compliance, and payer specificity—building the foundation for faster, more reliable authorization decisions.

A Day in the Life

• Own the end-to-end process of translating payer and evidence-based policies into structured clinical decision logic
• Validate and approve AI-generated prior authorization recommendations for medications and biologics under both medical and pharmacy benefits
• Lead policy interpretation, guideline review, and benefit mapping to ensure all AI-driven workflows align with payer intent and coverage rules
• Partner with product, engineering, and AI teams to define requirements, validate outputs, and guide the design of clinical decision trees
• Establish and maintain a structured review process for policy updates, FDA approvals, and clinical guideline changes
• Develop and maintain a comprehensive pharmacy and medical benefit knowledge base to support scalable automation
• Identify gaps, lead refinements, and set quality standards for clinical decision support and automation accuracy
• Communicate policy changes, audit findings, and enhancement recommendations to cross-functional stakeholders

 What You Need

• Licensed Pharmacist (PharmD or RPh) in good standing
• 3+ years of experience in pharmacy utilization management, prior authorization, or medical policy review in a payer, PBM, or health system setting.
• Proven ability to lead and own clinical policy translation and review workflows.
• Strong understanding of specialty and biologic drug reviews, including step therapy, quantity limits, and medical benefit determinations.
• Working knowledge of HCPCS, CPT, and NDC coding for medication-related services.
• Experience interpreting payer drug policies and clinical criteria such as NCCN, ASCO, and FDA labeling.
• Demonstrated comfort working cross-functionally with product and engineering teams on clinical logic design.
• Excellent analytical, critical thinking, and problem-solving skills with strong attention to clinical and regulatory detail.
• Clear communication and documentation skills, with the ability to lead discussions and decisions across clinical and technical teams.

Preferred Skills

• Experience developing or maintaining payer pharmacy or medical policies
• Familiarity with evidence-based guideline development or health informatics
• Certification in pharmacotherapy, informatics, or medical coding (e.g., BCPS, CPHIMS, CPC)
• Experience leading validation or implementation of AI, automation, or clinical decision support systems
• Ability to drive process improvement and lead clinical quality initiatives in a fast-paced, innovative environment

We offer competitive benefits to set you up for success in and outside of work.

Here’s What We Offer

• Generous Paid Time Off: Recharge and relax with 22 days of fixed time off per year, in addition to company holidays—because we believe work-life balance fuels performance.
• Best-in-Class Parental Leave: Spend quality time with your growing family. We offer one of the industry’s most generous parental leave policies to support you during life’s most important moments.
• Recognition & Rewards: We celebrate wins—big and small. Get rewarded with monetary incentives and company-wide recognition for your impact and dedication. Your hard work won’t go unnoticed.
• Comprehensive Insurance Coverage: Stay covered with medical, dental, and vision insurance, plus 100% company-paid short- and long-term disability and basic life insurance. Optional perks include discounted legal aid and pet insurance.

Innovaccer Inc. is an equal opportunity employer. We celebrate diversity and are committed to fostering an inclusive workplace where all employees feel valued and empowered regardless of any characteristic protected by federal, state or local law including, without limitation, race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, medical condition, disability, age, marital status, or veteran status. Innovaccer Inc. participates in the E-Verify program to confirm employment eligibility of all newly hired employees based out of the U.S. and employed by Innovaccer Inc.

For any additional information, please visit the below websites:

E-Verify

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Right to Work (Spanish)

Disclaimer: 

Innovaccer does not charge fees or require payment from individuals or agencies for securing employment with us. We do not guarantee job spots or engage in any financial transactions related to employment. If you encounter any posts or requests asking for payment or personal information, we strongly advise you to report them immediately to our HR department at [email protected]. Additionally, please exercise caution and verify the authenticity of any requests before disclosing personal and confidential information, including bank account details.