Job Description

Job Title: Pharmacy Clinical Review Specialist I - Health Plan
Job ID: 52769415
Status: Full-Time
Regular/Temporary: Regular
Shift: Day Job
Facility: UPMC Health Plan
Location: 600 Grant St, Pittsburgh PA 15219


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.


  • Provide excellent internal and external customer service maintaining a second requests for information and customer complaint goal of zero.
  • Act as a conduit of information between the Pharmacy Service Representatives and the clinical staff
  • Subject matter expert on formulary exceptions and prior authorization requirements/time frames according to line of business.
  • Perform peer reviews of prior authorization requests.
  • Maintain or exceed designated quality and production standards.
  • 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.
  • Complete standard/expedited pharmacy coverage determinations according to departmental/government guidelines.
  • Report and respond to escalate issues and concerns in a within twenty-four hours.
  • 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.


  • HS diploma and 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 UPMC's 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/Disability/Veteran

Salary Range: $15.58 to $24.54 / hour

Union Position: No

Apply Current Employee?


At UPMC, our shared goal is to create a cohesive, positive, experience for our employees, patients, health plan members, and community. If you too are driven by these values, you may be a great fit at UPMC!


UPMC provides a total rewards package that can help you achieve the goals you have for your career and your personal life. Whether you want to learn a new skill through a training course, reach personal health and wellness targets, become more involved in your community, or follow a career path that provides you with the right experience to be successful, UPMC can help you get to where you want to be.


Now more than ever, YOU can help us shape our communities and UPMC into a better place for everyone to work, study, play, and thrive.

Learn more about working here and check out our policies and recent updates.

UPMC Health Plan Named Best Places to Work for LGBTQ Equality in 2019

UPMC Ranked #1 Best Places for Women and Diverse Managers in 2019

Talent Network