PHARMACIST

Job Summary:The Clinical Pharmacist supports managed pharmacy operations across Medicare Advantage and Medi-Cal, with a primary focus on utilization management, prior authorization, formulary management, and specialty pharmacy cost optimization. The role leverages clinical expertise, pharmacy claims analytics, and evidence-based practices to improve medication access, quality performance, HEDIS and Medicare Star Ratings, and population health outcomes. Working collaboratively with health plans, providers, and internal teams, the pharmacist supports regulatory compliance, provider engagement, and value-based care initiatives to promote appropriate medication use and manage total cost of care.Responsibilities:Utilization Management & Medication ReviewReview outpatient prior authorizations (PAs), and specialty drug requests using applicable Medi-Cal, Medicare, and Vivant Health criteria.Apply formulary requirements, step therapy, and evidence-based guidelines; recommend therapeutic alternatives when appropriate.Support coverage determinations, appeals, and clinical documentation.Conduct targeted medication reviews, including MTM, CMRs, TMRs, medication reconciliation, and adherence interventions for high-risk or priority members.Review flagged pharmacy claims, high-cost therapies, and high-utilization specialties for clinical appropriateness and cost impact.Support transitions of care and brief patient counseling for selected cases.Quality Improvement & Population HealthSupport priority HEDIS and Medicare Star Ratings measures, particularly medication adherence and access.Collaborate with Quality, Population Health, and Care Management teams on targeted pharmacy interventions.Conduct periodic performance reporting and participate in focused quality improvement initiatives.Compliance, Program Oversight & Cost ManagementMaintain compliance with applicable CMS, DHCS, NCQA, URAC, and organizational requirements.Support pharmacy-related audits, accreditation activities, and utilization management documentation.Analyze selected high-cost or high-frequency therapies and identify opportunities to improve cost-effectiveness.Review flagged cases for potential fraud, waste, and abuse.Collaboration & External PartnershipsServe as a pharmacy resource for clinical, care management, and provider-relations teams.Collaborate with providers and health plans on prior authorizations, formulary issues, drug utilization, and coverage criteria.Manage pharmacy-related programs and collaboration with local educational institutions.Participate in scheduled health plan meetings, case conferences, and targeted provider education.Provide education on pharmacy policies, utilization criteria, and relevant regulatory updates.Other FunctionsEnforces Company policies and safety procedures.Regularly updates job knowledge by participating in educational opportunities, reading professional publications, maintaining professional networks, and participating in professional organizations.Maintain IPA, Health Plan compliance standards.Other duties as assigned.CompetenciesMinimum of 3–5 years of clinical pharmacy experience, preferably in managed care, health plan operations, or population health management.Experience supporting managed care pharmacy programs, Medicare Advantage, Medi-Cal, and Medicare Part D.Demonstrated expertise in utilization management, prior authorization, formulary management, medication therapy management (MTM), and evidence-based clinical review.Experience supporting Pharmacy and Therapeutics (P&T) Committee activities, including formulary evaluation, clinical review, and assessment of therapeutic alternatives, preferred.Working knowledge of applicable CMS, DHCS, NCQA, URAC, regulatory, accreditation, and organizational requirements.Knowledge of HEDIS measures, Medicare Star Ratings, CAHPS, population health management, quality improvement, and value-based care initiatives.Strong analytical skills with experience evaluating pharmacy claims, utilization trends, specialty pharmacy costs, clinical information, and total cost of care to identify opportunities for improved quality, outcomes, and cost effectiveness.Demonstrated ability to collaborate effectively with providers, health plans, pharmacy partners, and interdisciplinary teams on medication management, clinical policies, utilization initiatives, and quality improvement efforts.Excellent oral and written communication, presentation, and interpersonal skills, with the ability to communicate clinical and technical information effectively to diverse audiences.Proficiency with Microsoft Office and pharmacy and clinical information systems, with the ability to learn and effectively use new applications and technologies.Ability to work independently, exercise sound professional judgment, prioritize competing responsibilities, and collaborate effectively in a fast-paced team environment.Demonstrated commitment to confidentiality, accuracy, continuous learning, regulatory compliance, and high-quality service.Ability to maintain a professional demeanor and effectively represent the Company in interactions with providers, health plans, vendors, members, and other stakeholders.Education and LicensureDoctor of Pharmacy (PharmD) degree from an accredited program.Active California pharmacist license in good standing.Board certification (BCPS, BCACP, or relevant specialty) preferred. #J-18808-Ljbffr