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Remote Utilization Management Pharmacist Jobs in Raleigh, NC

Valeris

Executive Case Manager (Remote)

Raleigh, NC · Remote

... management to patients and HCPs including outbound communication to HCPs, specialty pharmacies and ... Remote work eligibility is subject to all work from home criteria met and based on business need ...

Aprio

Senior Director, Resource Management

Raleigh, NC · On-site +1

$225K - $300K/yr

Analyze trends in utilization and availability to drive redeployment of team members across offices ... remote and hybrid options What's in it for you: - Working with an industry leader : Be part of a ...

Bavariannordic

Manager, Field Force Enablement

Durham, NC · Remote

$120K - $150K/yr

Remote, United States (Headquarters: Durham, NC) Department: North America Commercial - Field Force ... Support adoption and effective utilization of enablement platforms and tools (e.g., Veeva, CRM ...

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How much do remote utilization management pharmacist jobs pay per hour?

As of Jul 15, 2026, the average hourly pay for remote utilization management pharmacist in Raleigh, NC is $56.48, according to ZipRecruiter salary data. Most workers in this role earn between $45.34 and $66.83 per hour, depending on experience, location, and employer.

How does a Remote Utilization Management Pharmacist typically collaborate with other healthcare professionals while working offsite?

Remote Utilization Management Pharmacists work closely with physicians, nurses, and case managers primarily through secure digital platforms and regular conference calls. They review medication requests, provide clinical recommendations, and help ensure patients receive appropriate therapies in line with established guidelines. Effective communication and timely documentation are essential, as collaboration often relies on electronic health records and virtual meetings. Building strong professional relationships remotely can be a challenge, but most organizations provide robust digital tools and dedicated support teams to facilitate seamless interaction.

What are the key skills and qualifications needed to thrive as a Remote Utilization Management Pharmacist, and why are they important?

To thrive as a Remote Utilization Management Pharmacist, you need a Doctor of Pharmacy (PharmD) degree, active pharmacist licensure, and experience in medication review and clinical decision-making. Familiarity with pharmacy benefit management (PBM) systems, electronic health records (EHRs), and utilization management software is typically required. Strong analytical skills, attention to detail, and effective written communication are vital for evaluating medication requests and collaborating with healthcare providers. These competencies ensure appropriate medication use, regulatory compliance, and optimal patient outcomes in a remote healthcare setting.

What is a Remote Utilization Management Pharmacist?

A Remote Utilization Management Pharmacist is a licensed pharmacist who works from a non-traditional setting, such as home, to review medication use and ensure that prescribed drugs are medically necessary, cost-effective, and aligned with clinical guidelines. They collaborate with healthcare providers, insurance companies, and patients to optimize medication therapy while controlling costs and preventing unnecessary treatments. Their work often involves evaluating prior authorization requests, reviewing patient medication histories, and providing recommendations for alternative therapies when appropriate.

What is the difference between Remote Utilization Management Pharmacist vs Remote Pharmacy Benefits Manager?

AspectRemote Utilization Management PharmacistRemote Pharmacy Benefits Manager
CredentialsPharmacy license, certification in utilization reviewPharmacy license, health plan or benefits management experience
Work EnvironmentHealthcare organizations, insurance companies, telehealth platformsHealth insurance companies, pharmacy benefit management firms
Industry UsageFocuses on medication review, prior authorizations, and clinical decision supportOversees pharmacy benefit plans, formulary management, and cost control strategies

While both roles involve pharmacy expertise and work remotely, the Remote Utilization Management Pharmacist primarily reviews medication appropriateness and manages prior authorizations, whereas the Remote Pharmacy Benefits Manager focuses on managing pharmacy benefit plans and formulary strategies. Understanding these distinctions helps professionals choose the role that best aligns with their skills and career goals.

What are the most commonly searched types of Utilization Management Pharmacist jobs in Raleigh, NC? The most popular types of Utilization Management Pharmacist jobs in Raleigh, NC are:
What are popular job titles related to Remote Utilization Management Pharmacist jobs in Raleigh, NC? For Remote Utilization Management Pharmacist jobs in Raleigh, NC, the most frequently searched job titles are:
What job categories do people searching Remote Utilization Management Pharmacist jobs in Raleigh, NC look for? The top searched job categories for Remote Utilization Management Pharmacist jobs in Raleigh, NC are:
What cities near Raleigh, NC are hiring for Remote Utilization Management Pharmacist jobs? Cities near Raleigh, NC with the most Remote Utilization Management Pharmacist job openings:
Remote Utilization Management Pharmacist jobs near you
Dir-Utilization Management-Physical Health (Full-time Remote, Morrisville, NC Based)

Dir-Utilization Management-Physical Health (Full-time Remote, Morrisville, NC Based)

Alliance

Morrisville, NC • On-site, Remote

Full-time

Re-posted 28 days ago

Job description

The Director of Utilization Management (UM) for Physical Health is responsible for administering and coordinating physical health utilization management activities for Alliance. This position ensures the UM Department operates as an integrated department providing a holistic review of member's needs. The position is responsible for overseeing a core component that ensures that individuals receive the correct level and intensity of services that results in positive outcomes. This job also develops systems to monitor the appropriate utilization of both state and Medicaid funds.
This position is full-time remote. Selected candidate must reside in North Carolina and be willing to travel to the home office (Morrisville, NC) for onsite team meetings as needed.
Responsibilities & Duties
Develop and implement Unit goals and objectives
  • Integrate the department and its functions into the organization's primary mission.
  • Ensure the Utilization Management Department serves as an integrated department through effectively collaborating with the Director of Behavioral Health Utilization Management and the Sr. Director of Utilization Management

Manage and Develop Staff
  • Work with Human Resources and the Sr. Director of UM to maintain and retain a highly qualified and well-trained workforce.
  • Ensure staff are well trained in and comply with all organization and department policies, procedures, and business processes.
  • Organize workflows and ensure staff understand their roles and responsibilities.
  • Ensure the department has the needed tools and resources to achieve organizational goals and to support employees and ensure compliance with licensure, regulatory, and accreditation requirements.
  • Actively establish and promote a positive, diverse, and inclusive working environment that builds trust.
  • Ensure all staff are treated with respect and dignity
  • Ensure standards are transparent and applied consistently, impartially, and ethically over time and across all staff members.
  • Work to resolve conflicts and disputes, ensuring that all participants are given a voice.
  • Set goals for performance and deadlines in line with organization goals and vision.
  • Effectively communicate feedback and provide ongoing coaching and mentoring to staff and support a learning environment to advance team skills and professional development.
  • Cultivate and encourage efforts to expand cross-team collaboration and partnership.
  • Effectively utilize and teach to the team how to effectively utilize authorization, claims and per diem data in order to remain within Alliance's Cost of Care plan
  • Supervise UM Physical Health employees to assure accountability and productivity in meeting Department objectives and targets.

Oversee delegated UM vendors
  • Oversee delegated vendors performing utilization reviews for physical health services.
  • Monitor UM vendors for compliance with delegation agreements and corrective action plans.
  • Report analysis of non-compliance when identified.

Oversee the UM Unit reviewing physical health services
  • Ensure consistent application of medical necessity criteria for physical health services.
  • Participate in the development and implementation of department policies and procedures
  • Ensure compliance with performance measures outlined within NC DHB, NC DMH contracts and all accrediting body standards.
  • Protect client rights by ensuring all UM staff are trained and follow due process procedures, including the timely processing of treatment requests.
  • Implement a system to maintain and assure that the authorization of services provided by clinical care staff appropriately address the service needs, types of service, outcomes, and alternatives available to consumers.
  • Refine and evaluate the methods of authorization for services and treatment; develop strategies for accessing alternative to care.
  • Provide education to hospitals, nursing homes and other care providers concerning departmental procedures and requirements for approving length of stay extensions.
  • Analyze and monitor community capacity for service needs, service gaps, and the implementation of evidence based/best practices.
  • Advise on the Alliance Medicaid and Non-Medicaid benefit plans that support the delivery and fidelity of evidence-based practices.
  • Implement and montior systems to detect patterns of over and under utilization and implements corrective plans.
  • Advise the Utilization Management Committee regarding service line trends and operational key performance measures.
  • Perform other related duties as required by the immediate supervisor or other designated Alliance Health administration

Inter-Departmental Collaboration
  • Maintain accessible and close working relationships with all applicable department heads and decision makers to develop a more coordinated and streamlined service delivery system for individuals and families throughout the service area.
  • Identify opportunities for collaboration on inter-departmental projects that reduces duplication and ineffenciencies across the system.
  • Work with the Medical Directors with decision making of medical necessity cases, specialists, and primary care physicians

Minimum Education & Experience
Bachelors in Nursing with seven (7) years' post-degree experience, including at least two (2) years of supervisory experience and two (2) years Utilization Management or substantially equivalent experience;
OR
Master's degree in Nursing and five (5) years' experience including at least two (2) years of supervisory experience and two (2) years Utilization Management experience or substantially equivalent experience.
Knowledge, Skills, & Abilities
  • Must be knowledgeable in Utilization Management managed care principles and strategies
  • Knowledge of physical health and co-morbid health conditions
  • Knowledge of diagnostic treatment guidelines/protocols, level of care criteria
  • Authorization/re-authorization Utilization Management standards
  • Ability to analyze data and develop corresponding strategies
  • Ability to develop and document workflows
  • Written and oral communication skills
  • Ability to analyze effectiveness of processes and make adjustments to developed processes.
  • Experience in acute clinical utilization review
  • Experience in related duties in the delivery of patient care, management of patient care providers, or project management in a healthcare environment
  • Demonstrates ability to interact with a wide variety of individuals, and handle complex and confidential sensitive situations.
  • Able to lead, delegate and problem solve
  • Proficient in the use of computer and multiple software programs.
  • Ability to assist appeal efforts when medical care is denied by various payor entities in a timely fashion.

Employment for this position is contingent upon a satisfactory background check, which will be performed after acceptance of an offer of employment and prior to the employee's start date.
Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.
Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.
For further information, please review the Know Your Rights notice from the Department of Labor.

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