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Remote Utilization Review Jobs in Worcester, MA (NOW HIRING)

RPh on the Go

Pharmacist in Worcester, MA

Worcester, MA · Remote

$55 - $65/hr

A remote Pharmacist opportunity is available for a dedicated professional seeking a 6-month ... Experience with Part B prior authorization and appeals review preferred * Prior utilization ...

New

RPh on the Go

Pharmacist in Leominster, MA

Leominster, MA · On-site +1

$55 - $65/hr

A remote Pharmacist opportunity is available on a temp-to-hire basis, offering the chance to ... Experience handling Part B drug prior authorization and appeals reviews. * Prior utilization ...

New

UnitedHealth Group

Patient Care Coordinator

Worcester, MA · On-site +1

$17.50 - $23/hr

Reviews and facilitates the updating of missing /outdated information in the patient record with ... Ability to work collaboratively with interdisciplinary teams consisting of remote and onsite staff ...

VIVA USA INC

Nurse Case Manager

Woonsocket, RI · On-site +1

Fully remote (never coming onsite) Description: The Case Manager utilizes a collaborative process ... Through the use of clinical tools and information/data review, conducts comprehensive assessments ...

VIVA USA INC

Nurse Case Manager

Woonsocket, RI · On-site +1

Fully remote (never coming onsite) Description: The Case Manager utilizes a collaborative process ... Through the use of clinical tools and information/data review, conducts comprehensive assessments ...

All JobsUtilization Review JobsRemote Utilization Review JobsRemote Utilization Review Jobs in Worcester, MA

Remote Utilization Review information

See Worcester, MA salary details

$21

$42

$68

How much do remote utilization review jobs pay per hour?

As of Aug 29, 2026, the average hourly pay for remote utilization review in Worcester, MA is $42.19, according to ZipRecruiter salary data. Most workers in this role earn between $33.32 and $48.46 per hour, depending on experience, location, and employer.

What is a remote utilization review?

A Remote Utilization Review job involves assessing medical records and treatment plans to ensure they meet insurance guidelines and medical necessity criteria. Professionals in this role, often nurses or healthcare specialists, work remotely to review patient care for cost-effectiveness and compliance with policies. They collaborate with healthcare providers, insurance companies, and case managers to approve or deny services based on established guidelines. This position requires strong analytical skills, knowledge of medical policies, and attention to detail.

What does a remote utilization review do?

A typical day for a Remote Utilization Review professional involves reviewing patient medical records, evaluating the necessity of proposed treatments against established guidelines, and collaborating with healthcare providers to gather additional information when needed. You will spend much of your time analyzing documentation, submitting recommendations, and ensuring that care authorization decisions align with payer policies and clinical best practices. Communication with case managers, physicians, and insurance representatives is frequent and essential. The work is generally independent and deadline-driven but requires strong teamwork and responsiveness through virtual meetings, emails, and calls.

What are the key skills and qualifications needed to thrive in remote utilization review?

To thrive as a Remote Utilization Review professional, you need a solid foundation in clinical knowledge, critical thinking, and an active RN or LPN license, often supported by experience in case management or prior authorization. Familiarity with medical coding (ICD-10, CPT), electronic health records (EHRs), and utilization management software is typically required, along with URAC or related certifications. Excellent communication, attention to detail, and strong organizational skills help you efficiently manage cases and coordinate with providers and payers. These skills ensure accurate assessments of medical necessity, compliance with regulations, and effective remote collaboration with healthcare teams.

What are the most commonly searched types of Utilization Review jobs in Worcester, MA?

The most popular types of Utilization Review jobs in Worcester, MA are:

What are popular job titles related to Remote Utilization Review jobs in Worcester, MA?

For Remote Utilization Review jobs in Worcester, MA, the most frequently searched job titles are:

What job categories do people searching Remote Utilization Review jobs in Worcester, MA look for?

The top searched job categories for Remote Utilization Review jobs in Worcester, MA are:

What cities near Worcester, MA are hiring for Remote Utilization Review jobs?

Cities near Worcester, MA with the most Remote Utilization Review job openings:

Remote Utilization Review jobs near you
Infographic showing various Remote Utilization Review job openings in Worcester, MA as of August 2026, with employment types broken down into 83% Full Time, and 17% Part Time. Highlights an 100% Remote job distribution, with an average salary of $87,755 per year, or $42.2 per hour.

Remote Pharmacist - Prior Authorization / Coverage Determination

Woonsocket, RI • Remote

A-Line Staffing Solutions
Recruiting and Staffing Services • 201 - 500 employees
Learn more about A-Line Staffing Solutionsexternal

$53/hr

Full-time

Medical, Dental, Vision

Re-posted 12 days ago

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Job description

Remote Pharmacist – Prior Authorization / Coverage Determination

Pay Rate: $53.00/hr

Start Dates

  • September 7
  • September 28

Training Requirements

  • Mandatory paid training is held Monday – Friday, 9:00 AM – 5:30 PM EST for approximately 8–10 weeks.
  • Attendance is mandatory during training. No planned vacation or scheduling conflicts are permitted during this period.
  • Candidates must be available for the entire training schedule before accepting the assignment.
  • Camera must remain on during all virtual training sessions, supervisor meetings, and team meetings.

Schedule

Business Hours:

  • Monday – Friday: 7:00 AM – 8:00 PM EST
  • Saturday & Sunday: 7:00 AM – 4:30 PM EST

Schedule Type: Set Rotation

After training, candidates will be assigned an 8-hour shift based on business needs, which will include either:

  • One weekend day each week, or
  • A rotating weekend schedule.


Job Summary

We are seeking a licensed Registered Pharmacist to support a high-volume, remote Prior Authorization and Coverage Determination team. This role is responsible for reviewing pharmacy benefit requests, interpreting clinical criteria, evaluating Medicare Part D coverage determinations, and ensuring accurate, timely decisions while maintaining compliance with regulatory requirements.

The ideal candidate has experience in Pharmacy Benefit Management (PBM), prior authorizations, managed care, or clinical pharmacy operations and thrives in a productivity-driven remote environment with strict turnaround times.

This is a Safety Sensitive position.

Key Responsibilities

  • Review and evaluate prior authorization and coverage determination requests.
  • Interpret Medicare Part D guidelines, formulary requirements, and clinical criteria.
  • Apply evidence-based clinical judgment using drug information resources and clinical compendia.
  • Ensure compliance with CMS regulations, plan policies, and pharmacy benefit guidelines.
  • Document case reviews accurately and maintain audit-ready records.
  • Manage a high-volume case queue while meeting quality and productivity standards.
  • Perform provider outreach as needed to obtain clinical information or clarify requests.
  • Navigate multiple applications simultaneously while documenting case activity.
  • Work independently in a fast-paced remote environment with minimal supervision.
  • Participate in virtual meetings, coaching sessions, and required training.

Required Qualifications

  • Active Registered Pharmacist (RPh) license in good standing in the state of residence.
  • Experience with:
    • Pharmacy Benefit Management (PBM)
    • Prior Authorizations
    • Coverage Determinations
    • Medicare Part D
    • Formulary management
    • Drug Utilization Review (DUR)
  • Strong understanding of CMS regulations and managed care pharmacy.
  • Excellent documentation and data entry skills.
  • Experience working in high-volume, productivity-driven environments.
  • Strong computer skills, including Microsoft Excel and Word.
  • Ability to navigate multiple computer applications using dual monitors.

Preferred Qualifications

  • Experience with provider outreach and clinical case review.
  • Retail pharmacy combined with managed care or PBM experience.
  • Knowledge of Microsoft Access, PowerPoint, and Visio.
  • Previous remote clinical review experience.

Remote Work Requirements

Candidates must have:

  • A dedicated, quiet workspace free from interruptions.
  • Wired high-speed internet with a minimum of:
    • 25 Mbps download
    • 5 Mbps upload
  • Dual-monitor capability.
  • Ability to remain seated and focused throughout the workday.

Additional Requirements

  • Virtual interviews are conducted through Microsoft Teams.
  • Candidates must be comfortable with extensive data entry, multitasking, and working independently while maintaining productivity standards.
  • Opportunity for full-time employment based on performance.
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About A-Line Staffing Solutions

Sourced by ZipRecruiter

A-Line Staffing Solutions is an established full-service recruiting and staffing provider that operates in the industry of human resources and recruitment. Based in Utica, Michigan, A-Line Staffing Solutions has been committed to its mission of providing innovative and effective workforce solutions since its foundation. The company specializes in providing high-quality staffing solutions for a range of disciplines, including Information Technology, Professional, Administrative, Healthcare, and more. A-Line prides itself on its ability to offer comprehensive and tailored staffing solutions in line with the varying needs of different businesses, which has played a crucial role in the company's growth and success.

Industry

Recruiting and staffing services

Company size

201 - 500 Employees

Headquarters location

Utica, MI, US

Year founded

2004

Social media

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