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 Review

• Review 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 Health

• Support 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 Management

• Maintain 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 Partnerships

• Serve 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 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.