Clinical Utilization Management Pharmacist

Who We Are Point32Health is a leading not‑for‑profit health and well‑being organization dedicated to delivering high‑quality, affordable healthcare. Serving nearly 2 million members, we build on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and shared values that guide our behaviors and decisions. We have a long‑standing commitment to inclusion and equal healthcare access and outcomes, and we value the mix of backgrounds, perspectives, and experiences of all colleagues. Job Summary Under the direction of the Pharmacy Utilization Management (UM) Supervisor, the Clinical Pharmacist reviews, processes, and manages the daily caseload of pharmacy prior authorization (PA) requests for coverage determinations (CD) and exceptions. The Clinical Pharmacist ensures timely disposition of reviews for CD and exceptions by adhering to established timeframes and consults with THP Medical Directors (MD) on prior authorizations that fail to meet drug prior authorization criteria. Key Responsibilities Perform case reviews in automated prior authorization (Auto PA) tools and guide the case through the entire process to either approval or denial, ensuring all coverage determinations and notices are consistent with applicable regulatory and accreditation requirements and turnaround times. Provide all aspects of clinical support needed to perform PA requests and consult with THP MDs on cases that fail to meet coverage criteria. Communicate daily with members, providers, and other external customers regarding status and disposition of cases. Oversee and address quality issues with pharmacy technicians and confer with clinical pharmacists on review questions. Communicate with UM staff and providers when issues arise regarding policy interpretation, potential access availability, or other quality assurance issues, ensuring members receive coverage determinations within established timelines. Facilitate communication between the Pharmacy UM department and other internal Tufts Health Plan departments by acting as a liaison or committee member on the development or implementation of new programs. Perform other roles, duties, and projects as assigned by the Pharmacy UM Supervisor or Manager. Provide subject‑matter expertise for the integrated team and support members’ medication management needs, including medication reviews, reconciliation, and coordination with the care team. Serve as the medication expert for patients, providers, and care team members, collaborating with the care team in care management, coordination of care, and care planning in transitions of care. Participate in risk management activities, including identifying and communicating issues of risk in a timely manner. Submit timely documentation in the care management information system and represent Point32Health professionally. Play a key role in administrative support and performance management, collecting and analyzing related data, adhering to departmental policies, and maintaining HIPAA standards. Perform other duties and projects as assigned. Education and Licensure Minimum: Bachelor of Science in Pharmacy or PharmD. Current registration and good standing with the Board of Pharmacy. Licensed to practice pharmacy in Massachusetts; current and valid Massachusetts pharmacist license. Certification by the Board of Pharmacy Specialties in a relevant area (e.g., BCACP, BCGP, BCPP, BCPS). Preferred: PharmD from an ACPE‑accredited school of pharmacy. Experience Minimum: 3 years full‑time experience as a pharmacist, preferably in PBM and/or managed care setting; 5 or more years of progressive clinical pharmacy experience in managed care, facility, and retail setting, including 2 years in an ambulatory setting. Expert knowledge of pharmaceutical science, federal and state controlled substance laws, and drug coding (NDC, GCN, GPI, USC). Knowledge of NCPDP claims adjudication systems and previous experience with MedHOK, RxClaim, CCMS, and CAS systems a plus. Knowledge of or experience with Medicare Part B & D, Medicaid, and Drug Utilization Management. Prior authorization experience, including reviewing drug use criteria for medication approval. Experience in care management, high‑risk population, and/or transitions of care. Skill Requirements Analytical ability to independently research and summarize data on drug utilization and spend. Excellent written and verbal communication skills. Strong PC skills with MS Office (Word, Excel, PowerPoint & Access) and ability to learn new database and reporting applications. High degree of professionalism and confidence; ability to recognize politically sensitive issues and use diplomacy. Capable of interacting effectively with all levels of management. Self‑motivated and able to work independently with minimal supervision. Organizational skills to manage several projects simultaneously; flexible and able to adjust priorities frequently. Ability to practice in an interdisciplinary team‑based model. Working Conditions Travel to member residences and outside meetings. Work under normal office conditions with the possibility to work from home as required. Use of telephone/headset and PC/keyboard simultaneously, with extended sitting durations. May be required to work additional hours beyond the standard schedule. Disclaimer The above statements describe the general nature and level of work being performed by employees assigned to this classification. They are not an exhaustive list of all responsibilities, duties, and skills required. Management retains the discretion to add or change duties at any time. Salary Range $110,680.66 – $166,020.98 Benefits Overview Medical, dental, and vision coverage. Retirement plans. Paid time off. Employer‑paid life and disability insurance with additional buy‑up options. Tuition program. Well‑being benefits. Full suite of benefits to support career development, individual & family health, and financial health. EEO Statement All applicants are welcome and will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. 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