Health Plan Pharmacist

Health Plan Pharmacist

Location: 100% onsite in Huntington Beach, CA. This role requires working in the office five days per week.

Impresiv Health is seeking an experienced Health Plan Pharmacist to support Medicare Advantage pharmacy operations, clinical programs, and regulatory compliance initiatives. This role serves as a subject matter expert in pharmacy benefit management, formulary oversight, medication therapy management, drug utilization review, and CMS Medicare Part D compliance. The Health Plan Pharmacist will collaborate closely with medical directors, care management, quality improvement, analytics, and pharmacy benefit management (PBM) partners to improve member outcomes, optimize medication use, and support high-performing Medicare Star Ratings initiatives.

What You Will Do:

• Manage Medicare Part D formulary activities, including drug tier placement, prior authorization criteria, step therapy protocols, quantity limits, and formulary exception reviews.
• Support Pharmacy and Therapeutics Committee activities, including drug monograph preparation, clinical policy updates, and formulary management recommendations.
• Monitor CMS formulary compliance, annual bid submissions, formulary change notifications, transition of care requirements, and related operational processes.
• Collaborate with PBM partners on rebate strategy, generic utilization initiatives, specialty drug management, and pharmacy benefit performance.
• Oversee prospective and retrospective Drug Utilization Review programs to identify high-risk medication use, drug-drug interactions, and opportunities for intervention.
• Develop, support, and monitor Medication Therapy Management programs, including Comprehensive Medication Reviews and Targeted Medication Reviews.
• Support adherence programs for chronic disease medications, including diabetes, hypertension, COPD, and other key Star Ratings measure areas.
• Conduct clinical reviews for prior authorization and coverage determination requests in accordance with CMS requirements and required timelines.
• Lead pharmacy-related quality improvement initiatives focused on Part D adherence, CMR completion, high-risk medication use, and overall Stars performance.
• Support CMS audits, mock audits, corrective action plans, Annual Notice of Change requirements, coverage determinations, appeals, and pharmacy compliance activities.
• Monitor evolving CMS guidance, including IRA drug pricing provisions, Low-Income Subsidy policies, and Medicare Part D out-of-pocket cap requirements.
• Identify high-risk members with complex medication regimens and collaborate with care management teams to develop individualized medication management plans.
• Support D-SNP and dual-eligible pharmacy needs, including Medicare Part D and Medicaid pharmacy benefit coordination.
• Serve as a clinical resource for member and provider inquiries related to formulary alternatives, prior authorization requirements, and covered drug options.
• Analyze pharmacy claims data to identify cost drivers, utilization trends, clinical outliers, and opportunities for improved outcomes.
• Develop and maintain pharmacy performance dashboards tracking metrics such as generic dispensing rate, medication adherence, PA approval and denial trends, MTM engagement, and pharmacy program performance.
• Partner with analytics and finance teams to support pharmacy trend forecasting, bid modeling, and Medicare Advantage benefit design.

You Will Be Successful If:

• You have strong working knowledge of Medicare Part D operations, CMS pharmacy compliance requirements, formulary administration, and coverage determination processes.
• You can translate complex clinical, regulatory, and pharmacy claims data into clear recommendations for clinical teams, operational leaders, and plan leadership.
• You understand pharmacy-related CMS Star Ratings measures and can support initiatives that improve adherence, medication safety, MTM engagement, and member outcomes.
• You are comfortable working cross-functionally with medical management, care management, quality, utilization management, analytics, finance, compliance, and PBM partners.
• You can balance clinical appropriateness, regulatory requirements, member experience, and cost-effectiveness in a Medicare Advantage managed care environment.
• You are able to support high-risk Medicare, D-SNP, and dual-eligible populations with a member-centered approach.
• You can communicate clinical and regulatory information clearly to both clinical and non-clinical audiences.
• You stay current on CMS guidance, Medicare Advantage pharmacy trends, IRA-related operational changes, and evolving managed care pharmacy practices.

What You Will Bring:

• Doctor of Pharmacy degree from an ACPE-accredited institution.
• Active, unrestricted pharmacist license in the state of [State]; multi-state licensure preferred.
• Minimum of 35 years of pharmacy experience in a managed care, health plan, or PBM environment.
• Direct experience with Medicare Part D operations, including formulary management, CMS compliance, prior authorization, and coverage determinations.
• Working knowledge of CMS Star Ratings pharmacy measures and MTM program requirements.
• Experience reviewing pharmacy claims data and translating findings into clinical and operational insights.
• Experience participating in or presenting to clinical committees, such as Pharmacy and Therapeutics, Quality Improvement, or Utilization Management committees.
• Board certification in Pharmacotherapy or Geriatric Pharmacy preferred.
• Experience supporting D-SNP, dual-eligible, Medicare, or complex care populations preferred.
• Familiarity with IRA drug pricing provisions and their operational impact on Medicare Advantage plans preferred.
• Knowledge of specialty pharmacy management, site-of-care optimization, specialty benefit carve-out strategies, and high-cost medication management preferred.
• Experience with pharmacy analytics platforms such as Cotiviti, Inovalon, MedInsight, Tableau, Power BI, or similar tools preferred.
• Strong analytical, communication, collaboration, and regulatory interpretation skills.

About Impresiv Health:

Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.

Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.

That's Impresiv!