About this role
The Clinical Pharmacist Utilization Management serves a critical role across utilization management, quality improvement, and regulatory compliance for Medicare Advantage and commercial pharmacy benefits. This position makes accurate, evidence-based coverage determinations and appeal decisions. It supports pharmacy quality initiatives tied to CMS Star Ratings and ensures compliance with CMS regulations.
The pharmacist functions in a highly cross-functional capacity, partnering with operations, quality, compliance, vendors, providers, and customer service teams. These collaborations improve medication access, safety, adherence, and member experience across all lines of business. Daily tasks include clinical reviews and regulatory adherence.
Key activities involve performing Part B and Part D coverage determinations, conducting drug utilization reviews, and managing quality programs impacting CMS Star Ratings. The role provides Medication Therapy Management services and supports CMS audits and grievances. Vendor management and telephonic member outreach are also essential.
This position offers opportunities to assist with Pharmacy and Therapeutics subcommittee materials and drive biosimilar conversions. It enhances member outcomes through interventions and outreach. Professionals contribute to regulatory reporting and formulary compliance in a dynamic healthcare environment.
Requirements
- Pharm.D. or RPh from an accredited School of Pharmacy
- Active, unrestricted pharmacist license in California
- Medicare Advantage Part B and Part D utilization management experience preferred
- Strong analytical, organizational, and written/verbal communication skills
Responsibilities
- Perform Part B and Part D coverage determinations and appeals in accordance with CMS regulations, plan benefits, and evidence-based clinical guidelines
- Conduct clinical drug utilization reviews and apply formularies and preferred drug lists
- Manage pharmacy quality programs impacting CMS Star Ratings, medication adherence, and Medication Therapy Management (MTM)
- Provide medication therapy management (MTM) services, including outreach to members, providers, and pharmacies
- Support CMS audits, regulatory reporting, grievances, and PBM formulary compliance activities
- Manage pharmacy quality vendors, including MTM and medication adherence programs
- Assist in the preparation of materials or activities related to the Pharmacy and Therapeutics (P&T) and Utilization Management subcommittee
- Conduct telephonic member outreach to answer member questions, resolve issues, and close care gaps
- Complete interventions to improve biosimilar conversions across all lines of business
Benefits
- Salary Range: $129,000 – $169,000 per year (actual compensation varies by location, experience, education, and skill level)
- Equal Opportunity Employer
- Full-time (Exempt) Regular Position
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