About DME Serve:
Founded in 2021, DME Service Solutions, LLC strives to be the industry leader in global call center business process outsourcing service solutions. We are passionate about business growth, working to understand customers’ needs while collaborating to develop solutions. Our mission is to develop our clients’ brand value through positive customer experiences, while also helping them meet their strategic business goals. At DME Service Solutions, diversity, equity, and inclusion are more than words – it’s who we are. Our commitment to these values is unwavering. Our agents are passionate about serving communities of all backgrounds. Innovation and integrity are the core values of our business philosophy. Our employees receive a world-class employee experience and benefits, they pay that forward with their service to our clients and their customers. DME is dedicated to supporting the Healthcare industry; Our clients consist of biotech companies, medical device manufacturers and medical supply distributors
Key Responsibilities:
- Conduct prospective, concurrent, and retrospective utilization reviews for medications and pharmacy services in US insurance.
- Must have experience with InterQual, MCG tools
- Apply clinical criteria (e.g., CMS guidelines, FDA labeling, InterQual, MCG) to make coverage determinations.
- Review and process prior authorizations, step therapy, and quantity limit overrides.
- Collaborate with physicians, nurses, and customer service teams on clinical determinations.
- Document clinical decisions accurately within UR systems and according to regulatory requirements.
- Support appeals and grievance processes by reviewing denied claims and providing clinical input.
- Monitor and report utilization trends, potential fraud, waste, or abuse.
- Ensure compliance with federal and state regulations, NCQA/URAC standards, and plan policies.
Qualifications:
- Pharmacy College Graduate
- Active Pharmacist license
- 2–3 years of experience in managed care, clinical pharmacy, or utilization management.
- Strong knowledge of Medicare Part D, Medicaid formularies, and commercial insurance benefits.
- Familiarity with drug databases, claims systems, and prior authorization platforms.
- Excellent communication and critical thinking skills.
License/Certification
- Active Pharmacist license (Required)
