Job Description

Job Title: Pharmacy Clinical Review Specialist I- Health Plan
Job ID: 732550
Status: Full-Time
Regular/Temporary: Regular
Shift: Day Job
Facility: UPMC Health Plan
Location: 600 Grant St, Pittsburgh PA 15219


Do you have two years of pharmacy related experience?  Do you enjoy working in a collaborative environment?  If so, an opportunity as a Pharmacy Clinical Review Specialist I with UPMC Health Plan may be the perfect fit for you. In this role, you will oversee administrative and system processes that relate to pharmacy prior authorizations. Manage the first line clinical review of prior authorization requests on behalf of physicians and UPMC Health Plan members. Collaborate with clinicians regarding supporting medical documentation in accordance with formulary guidelines. Manage the quality review of requested prior authorizations.

  • Act as a conduit of information between the Pharmacy Service Representatives and the clinical staff
  • Complete standard/expedited pharmacy coverage determinations according to departmental/government guidelines.
  • Develop and maintain the pre-logic and clinical criteria in support of the prior authorization determination process.
  • Interface with other departments and identify medical documentation in support of prior authorization requests.
  • Maintain or exceed designated quality and production standards.
  • Perform peer reviews of prior authorization requests.
  • Process requests and inquiries in accordance with all governing regulatory agencies including but not limited to CMS, DPW, DHHS, HCFA, DOI and NCQA laws and standards.
  • Provide excellent internal and external customer service maintaining a second requests for information and customer complaint goal of zero.
  • Report and respond to escalate issues and concerns in a within twenty-four hours.
  • Subject matter expert on formulary exceptions and prior authorization requirements/time frames according to line of business.


  • HS diploma required. 
  • Pharmacy claims, pharmacy tech, and/or other related experience in a physician practice, ancillary provider, or other relevant healthcare setting required. 
  • Competent in pharmacy claims process operating system. 
  • Excellent knowledge in UPMCs Health Plan internal department functions. Excellent knowledge of medical terminology, coordination of benefits, complaints and grievance guidelines and prescription drug utilization management requirements.  
  • Thorough knowledge in MS Office and PC skills required. Organizational, analytical, interpersonal, and communication skills.  
  • Ability to prioritize and perform multiple tasks while maintaining designated production and quality standards. 
  • Staff is required to work scheduled overtime and be available for emergency overtime as business needs dictate.  
  • Staff is required to work a temporary, alternative schedule or shift as requested by supervisor.

Licensure, Certifications, and Clearances:
UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $15.13 to $23.82

Union Position: No

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