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

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.