[Remote] Staff Utilization Management Pharmacist at Humana

San Antonio, Texas, United States

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Not SpecifiedCompensation

Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, PharmaceuticalsIndustries

Requirements

Bachelor’s degree or Doctor of Pharmacy (Pharm.D.) from an accredited college of pharmacy
Active pharmacist license in the state of residence
Eligibility to participate in federal prescription programs (e.g., Medicare/Medicaid)
Self-directed with the ability to work effectively both independently and in a team environment
Strong problem-solving skills and the ability to foster collaborative solutions
High attention to detail with a strong work ethic focused on accuracy and productivity
Excellent verbal and written communication skills
Proficiency with computer systems, including Microsoft Office Suite (Word, Excel, Outlook), clinical decision support tools (e.g., Micromedex, Lexicomp), pharmacy benefit management (PBM) platforms, and electronic health records (EHRs)
Passion for contributing to an organization focused on continuously improving the consumer experience
Ability to work 8-hour shifts Monday-Friday (10:30 AM-11:00 PM EST) or 10-hour shifts Tuesday-Friday (10:30 AM-11:00 PM EST), every 5th Saturday, and 1 company holiday per year
Meet work-at-home (WAH) internet requirements: minimum download speed of 25 Mbps and upload speed of 10 Mbps (wireless, wired cable, or DSL suggested; satellite/cellular/microwave only if approved)
Work from a dedicated space lacking ongoing interruptions to protect member PHI/HIPAA information

Responsibilities

Conduct medical necessity and comprehensive medication reviews for prescriptions requiring prior authorization
Evaluate complex clinical scenarios and apply evidence-based criteria to ensure appropriate medication use
Address moderately complex to complex issues requiring critical thinking and in-depth analysis of variable factors
Conduct comprehensive reviews of medication care plans, including evaluating medical necessity, analyzing overall utilization, and identifying unusual usage patterns
Intervene and provide clinical guidance to patients and providers to support cost-effective medication use and promote high-quality patient outcomes

Skills

Key technologies and capabilities for this role

Pharm.D.Pharmacist LicenseUtilization ManagementPrior AuthorizationMedical Necessity ReviewMedication ReviewEvidence-Based CriteriaClinical AnalysisProblem-SolvingCritical Thinking

Humana

Health insurance provider for seniors and military

About Humana

Humana provides health and well-being services, focusing on Medicare Advantage plans for seniors, military personnel, and communities. Their plans include HMO, PPO, and PFFS options, designed to improve health outcomes through comprehensive and flexible coverage. Humana's revenue comes from government contracts and member premiums, and they aim to maintain high renewal rates by offering quality service and competitive benefits. The company stands out by fostering a culture of inclusivity and belonging among its employees, while also ensuring accessibility for all members, including offering free language interpreter services. Humana's goal is to deliver value to its members through an extensive provider network and innovative health solutions.

Louisville, KentuckyHeadquarters

1961Year Founded

IPOCompany Stage

Social Impact, HealthcareIndustries

10,001+Employees

Risks

Potential over-reliance on AI could disrupt operations if systems fail or are compromised.

Rising medical costs and tightening Medicare reimbursements may strain financial performance.

Leadership change with new CEO Jim Rechtin could lead to strategic disruptions.

Differentiation

Humana is a leader in Medicare Advantage plans, focusing on seniors and military personnel.

The company emphasizes inclusivity, offering free language interpreter services for accessibility.

Humana leverages AI and cloud technologies through a partnership with Google Cloud.

Upsides

Humana's investment in Healthpilot enhances digital enrollment for Medicare options.

The company is the first insurer to cover TMS therapy for adolescent depression.

Humana's focus on value-based care aims to improve outcomes for kidney disease patients.

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