About this role
CarelonRx, a member of the Elevance Health family, applies a clinical-first lens and deep pharmacy expertise to improve outcomes, control costs, and enhance member health. The Clinical Pharmacist manages pharmaceutical selection and utilization while supporting core programs like DUR, UM, and formulary management. This role combines structured office engagement with virtual flexibility.
Professionals in this position research and synthesize detailed clinical data on pharmaceuticals. They serve as clinical resources for other pharmacists on formulary, utilization management edits, and DURs. Coordination with operations ensures programs align with clinical intent.
Leads involve translating formulary and UM requirements into claims processing rules, including non-standard configurations. Develop build specifications and partner with operations and coding teams to implement and validate claim outcomes. The hybrid model requires 1-2 in-office days weekly for collaboration.
Interpret and operationalize Medicaid and state requirements, such as drug lists and PA rules. Create clear clinical criteria and configuration documentation for PA and claims systems. Provide independent oversight for consistent, compliant program setup in a dynamic workplace.
Requirements
- BA/BS in Pharmacy
- Minimum of 2 years of managed care pharmacy (PBM) experience or residency in lieu of work experience
- Registered pharmacist
- Current unrestricted Pharmacist license in applicable state(s)
- PharmD preferred
- Demonstrated experience with pharmacy claims processing and adjudication logic
- Proven ability to perform claims configuration and build support, including non-standard configurations
- Working knowledge of Medicaid and state program requirements
Responsibilities
- Research and synthesize detailed clinical data related to pharmaceuticals
- Serve as a clinical resource to other pharmacists on formulary, utilization management edits, DURs
- Coordinate with operations team to code programs to meet clinical intent
- Lead pharmacy claims adjudication configuration by translating formulary and utilization management requirements into claims processing rules and edits
- Develop build specifications and partner with operations and coding teams to implement and validate expected claim outcomes
- Interpret and operationalize Medicaid and state requirements by creating clear clinical criteria and configuration documentation for PA and claims systems
- Provide independent oversight to ensure consistent, compliant program setup
Benefits
- Hybrid work requiring 1-2 in-office days per week to foster collaboration
- Flexibility supporting productivity and work-life balance
- Alternate locations considered for candidates within commuting distance
- Dynamic and adaptable workplace environment
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