Remote Optum Utilization Review Jobs in California

At The Oncology Institute, our Utilization Management Pharmacists are clinical leaders who ensure safe, effective, and compassionate cancer care. You'll shape evidence-based treatment pathways, optimize therapies, and drive innovation that improves outcomes and reduces barriers for patients. Join a mission-driven team where your expertise directly impacts lives and the future of oncology.

REMOTE WORK FROM HOME

JOB PURPOSE AND SUMMARY

The Utilization Management Pharmacist supports the development, implementation, and ongoing optimization of oncology utilization management processes. This role applies clinical pharmacy expertise, evidence-based guidelines, payer policy knowledge, and formulary standards to promote appropriate therapy selection, reduce avoidable prior authorization friction, and support value-based oncology care.

The pharmacist partners with pharmacy leadership, physicians, advanced practice providers, revenue cycle management, informatics, and utilization management compliance teams to align medication review processes, pathway logic, evidence requirements, and operational workflows. The role also supports internal education and continuous improvement efforts related to medication utilization, preferred therapies, biosimilars, and payer-aligned criteria.

KEY RESPONSIBILITIES

- Review oncology medication requests and related clinical documentation for alignment with NCCN guidelines, TOI standards, payer medical policies, and internal formulary or pathway criteria.

- Support prior authorization and utilization management workflows by clarifying clinical rationale, identifying documentation gaps, and helping reduce avoidable delays in therapy access.

- Translate clinical criteria into clear pathway, checklist, or portal logic that supports consistent review of chemotherapy, immunotherapy, targeted therapy, biosimilars, supportive care medications, and other oncology agents.

- Partner with Revenue Cycle Management, Informatics, Medical Oncology leadership, and UM Compliance to keep EHR builds, UM portal criteria, payer requirements, and internal processes aligned.

- Maintain awareness of updates to NCCN, ASCO, FDA indications, payer medical policies, compendia, and state or federal utilization management requirements that may affect oncology medication review.

- Escalate clinically complex or non-standard cases to utilization management leadership and appropriate clinical stakeholders with clear recommendations and supporting evidence.

- Participate in process improvement initiatives, audits, and quality monitoring activities related to medication utilization management, documentation completeness, and pathway compliance.

- Implement mutually agreed upon therapeutic and supportive care medication use changes within the patient care setting for TOI Clinics.

REQUIRED QUALIFICATIONS AND SKILLS

Education and experience

- Doctor of Pharmacy (PharmD) from an ACPE-accredited School of Pharmacy.

- Active pharmacist license in good standing.

- Oncology pharmacy experience in a clinical, managed care, utilization management, specialty pharmacy, or related setting.

- Experience interpreting payer medical policies, prior authorization criteria, NCCN compendia, and oncology treatment guidelines.

Clinical, operational, and technical skills

- Strong knowledge of oncology therapeutics, including chemotherapy, immunotherapy, targeted therapies, biosimilars, and supportive care agents.

- Ability to convert clinical guidelines and payer criteria into practical review workflows, pathway logic, checklists, and clear documentation standards.

- Strong written communication skills with the ability to summarize evidence, criteria, and recommendations for clinical and operational audiences.

- Comfort working with EHRs, UM portals, payer policy resources, drug databases, spreadsheets, and reporting tools.

- Ability to analyze utilization patterns, identify workflow gaps, and recommend actionable improvements.

PREFERRED ATTRIBUTES

- Board certification in oncology pharmacy, such as BCOP, or demonstrated equivalent oncology expertise.

- Prior experience in utilization management, managed care, oncology pathways, payer criteria review, or value-based care initiatives.

- Collaborative, detail-oriented, and comfortable working in an evolving environment where workflows, standards, and digital tools continue to mature.

- Ability to balance clinical appropriateness, payer requirements, provider experience, operational efficiency, and patient access considerations.

PHYSICAL WORKING REQUIREMENTS

The position involves prolonged periods of sitting at a desk, extensive computer use, and phone or virtual meeting interaction. The role may require occasional lifting of up to 20 pounds for office supplies or equipment.

The physical demands described above are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.