PHARMACIST (3539)

Pharmacist

The Pharmacist manages core utilization review functions and supports targeted quality improvement initiatives across Medi-Cal and Medicare. This full-time role focuses on delivering high-value clinical reviews, supporting population health pharmacy priorities, and collaborating with health plans and providers on medication-related issues. The pharmacist will provide practical, focused support in prior authorization review, medication management, and performance improvement. This position emphasizes efficient case review, prioritized outreach, and participation in selected interdisciplinary activities to optimize patient outcomes and ensure regulatory compliance.

Responsibilities:

Utilization Review & Benefit Administration

• Conduct daily review of outpatient PAs, TARs, and specialty drug requests using Medi-Cal, Medicare, and Vivant Health criteria.
• Apply formulary guidelines, step therapy, and evidence-based standards to ensure appropriate, cost-effective medication use.
• Provide therapeutic alternatives and recommendations for non-formulary requests.
• Support coverage determinations, appeals, and documentation as needed.
• Comprehensive medication management (MTM, CMRs, TMRs) performed on a targeted basisfocused on high-risk or plan-prioritized members.
• Transitions of care and post-discharge medication reconciliation for select high-risk cases referred through care management.
• Patient counseling and disease state self-management support provided as brief, case-based interventions rather than ongoing longitudinal education.
• Prior Authorization Review Supporting Vivant Health in reviewing prior authorization requests as the primary UM workload.
• Pharmacy Claims Review performed for targeted cases (new drugs, outliers, or flagged claims) rather than universal claim review.
• High-Utilization Specialties reviewed only when flagged for clinical appropriateness or financial impact (e.g., oncology, rheumatology, dermatology).

Quality Management & Performance Improvement

• Support priority Star Ratings and HEDIS pharmacy measures, with an emphasis on medication adherence and access barriers.
• Collaborate with Population Health and Quality teams on select, high-impact, pharmacy-driven interventions.
• Population health initiatives, quality improvement, and performance reporting conducted on a scheduled, manageable cadence (e.g., monthly or quarterly reports).
• Medication Reconciliation & Adherence work performed through limited case review and provider collaboration on targeted patients.
• Participate in focused quality improvement activities aligned with the organization's highest-priority pharmacy metrics.

Program Oversight, Compliance & Cost Analysis

• Ensure compliance with CMS, DHCS, NCQA, and URAC for pharmacy utilization management and documentation.
• Provide subject matter expertise during audits and accreditation events when pharmacy elements are reviewed.
• Cost Impact Analysis performed for selected high-cost or high-frequency therapies to support decision-making and trend reporting.
• Monitor for fraud, waste, and abuse through review of flagged cases rather than broad surveillance.

Interdisciplinary Collaboration & Clinical Leadership

• Serve as a medication management resource for clinical and care management teams as questions arise.
• Interdisciplinary case conferences and care coordination attended selectivelyprioritizing cases where pharmacy input may meaningfully affect outcomes.
• Collaboration with providers on formulary management, drug utilization review, and prior authorizations conducted through scheduled communications or case-specific outreach.
• Provide internal education on UM criteria or pharmacy policies as needed (e.g., quarterly updates or targeted trainings).

Health Plan & External Partner Engagement

• Manage all pharmacy-related programs with California Northstate College of Pharmacy.
• Utilization Review with Health Plans by participating in scheduled meetings or case discussions related to pharmacy utilization.
• Provide input on discrepancies between provider requests and health plan criteria in a manageable, case-driven manner.
• Support provider education efforts during targeted outreach campaigns rather than broad trainings.

Other Functions

• Enforces 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.

Qualifications

Competencies

• Minimum 3-5 years of clinical pharmacy experience.
• Experience in managed care, health plan operations, or population health management preferred.
• Knowledge of Medi-Cal and Medicare Part D programs and regulations.
• Experience with MTM programs, prior authorization processes, and formulary management.
• Proficiency in pharmacy information systems and electronic health records.
• Strong analytical skills with experience in claims data analysis.
• Knowledge of clinical decision support tools and evidence-based medicine resources.
• Familiarity with quality measures (HEDIS, Medicare Stars, CAHPS).
• Strong clinical knowledge across therapeutic areas.
• Excellent communication (both oral and written) and interpersonal skills.
• Ability to work collaboratively in interdisciplinary teams.
• Strong problem-solving and critical thinking abilities.
• Attention to detail and ability to manage multiple priorities.
• Knowledge of regulatory requirements and compliance standards.
• Excellent active listening and critical thinking and analytical skills.
• Demonstrate leadership skills and initiative.
• Ability to provide and receive constructive job and/or industry related feedback.
• Ability to exercise sound discretion and strict maintenance of confidentiality of all confidential and sensitive communications and information.
• Ability to consistently deliver excellent customer service.
• Excellent attention to detail and ability to document information accurately.
• Ability to effectively and positively work in a dynamic, fast-paced team environment and achieve objectives.
• Demonstrate commitment to the organization's mission.
• Must have mid-level skills in Microsoft software (Word, Excel, PowerPoint, Visio) and Access is a plus.
• Typing speed of 40 wpm or more is a plus.
• Must have the ability to quickly learn and use new software tools.
• Must have mid-level skills using e-mail applications.
• Ability to work independently as well as in a team environment.
• Ability to present self in a professional manner and represent the Company image.

Education and Licensure

• Doctor of Pharmacy (PharmD) degree from an accredited program.
• Active California pharmacist license in good standing.
• Board certification (BCPS, BCACP, or relevant specialty) preferred.