Clinical Pharmacist

Clinical Pharmacist

At Western Health Advantage, we are committed to delivering high-quality, clinically sound, and member-focused healthcare solutions. As a Clinical Pharmacist supporting Prior Authorization Operations, you will play a vital role in ensuring safe, effective, and compliant medication use across our member population. This role offers a unique opportunity to apply your clinical expertise in a managed care environmentsupporting coverage determinations, influencing formulary strategy, and collaborating with cross-functional teams to improve outcomes and optimize care.

What You'll Do

Deliver Clinical Excellence

You will perform comprehensive clinical reviews of prior authorization (PA), exception, and appeal requestsleveraging clinical guidelines, drug information resources, and regulatory standards to ensure accurate and timely coverage determinations.

Ensure Regulatory Compliance

You will apply and uphold all applicable regulatory and accreditation standards (NCQA, DMHC, Board of Pharmacy, Knox-Keene), ensuring that all decisions and processes meet compliance requirements and organizational policies.

Collaborate & Communicate

You will serve as a clinical resource to internal teams and network providersclearly communicating decision rationale, supporting appeals, and contributing to pharmacy-related initiatives across the organization.

Support Formulary & Utilization Management

You will contribute to formulary development and maintenance, provide clinical input on PBM strategies and P&T committee outputs, and support updates to prior authorization criteria and preferred drug lists.

Drive Operational Excellence

You will participate in workflow optimization, quality improvement initiatives, and system enhancementshelping to improve efficiency, reduce errors, and strengthen overall pharmacy operations.

Key Responsibilities

• Review and evaluate prior authorization requests for outpatient and specialty medications
• Conduct drug utilization reviews in compliance with regulatory standards
• Research and apply current clinical data and therapeutic guidelines
• Support appeals and grievance processes related to pharmacy benefit determinations
• Collaborate with PBM partners on formulary management and drug product updates
• Monitor and update formulary listings and PA criteria
• Analyze pharmacy trends and support cost-of-care initiatives
• Provide education to providers and internal stakeholders on pharmacy programs
• Assist with regulatory audits (DMHC, NCQA) and accreditation activities
• Support training, documentation, and process development initiatives
• Participate in system testing, validation, and operational readiness efforts
• Provide cross-coverage support and ensure timely case completion

Qualifications

• Doctor of Pharmacy (PharmD) or equivalent required
• Active, unrestricted California Pharmacist license in good standing
• Minimum 4 years of pharmacy experience (retail, hospital, or mail order)
• 2+ years of managed care, PBM, or health plan experience preferred
• Experience with prior authorization review and utilization management
• Familiarity with formulary management and P&T committee processes preferred
• Proficiency in evaluating clinical literature and drug databases (e.g., UpToDate, DrugDex, NCCN)
• Strong computer skills including Microsoft Office and pharmacy systems

Why Western Health Advantage

Mission-Driven Work Contribute to improving healthcare quality and access across the communities we serve

Collaborative Culture Work alongside experienced clinicians and professionals in a supportive environment

Professional Growth Expand your expertise in managed care pharmacy, formulary strategy, and clinical operations

Meaningful Impact Play a key role in ensuring safe, effective, and cost-conscious medication

If you are a clinically driven pharmacist who thrives in a collaborative, fast-paced environment and is passionate about improving patient outcomes through thoughtful, evidence-based decisions, we encourage you to apply and be part of Western Health Advantage.