Job Description

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Job Description:

The Clinical Pharmacist, Utilization Management will be primarily responsible for the review of Part B and D coverage determination and appeal requests and render accurate clinical decisions in accordance with formulary benefits, guidelines, and CMS requirements. The pharmacist serves in a cross-functional role with other departments to support eligibility inquiries, claims adjudication, and drug coverage. This position will also support the Director of Pharmacy with clinical pharmacy services, including drug regimen review, monitoring drug/provider utilization patterns, patient/provider communications and education, and staff training across all lines of business, including Commercial.

REMOTE POSITION. The position requires a full-time work schedule supporting Pacific Standard Time as well as weekend on call support to meet business requirements.


The pharmacist is responsible for the oversight of the following functions and reports to the Pharmacy Director:

  • Part B drug utilization reviews, including administration of accurate clinical decisions by compiling relevant clinical information and applying evidence-based clinical guidelines/criteria and utilization of formularies/preferred drug lists.
  • Ensures that all Part B and Part D coverage determination and appeals, reporting elements, and submissions are met.
  • Identify and resolve issues and process gaps and escalate as applicable.
  • Research and respond to grievances and inquiries regarding coverage determinations, pharmacy benefit information, or therapeutic outcome optimization (i.e., medication selection, utilization, and adherence) and conduct outreach to prescribers, pharmacies, and members as needed.
  • Assist in preparation of materials or activities related to Pharmacy and Therapeutics (P&T), Utilization Management Subcommittee or other pharmacy-related Committees as assigned.
  • Contributes to pharmacy initiatives aimed at improving quality metrics or performance as needed.
  • Assist with regulatory and compliance reporting and audits.
  • Support cross-functional teams, including operations, compliance, and other pharmacy initiatives across all lines of business, as assigned or directed.
  • Medication Therapy Management: Provide medication therapy management including examination of member medical records, performing a comprehensive medication review and communicating with patients and providers, including outbound calls to patients to discuss their medications as needed.
  • Participate in special projects and assignments as needed and other duties as assigned.


Role Essentials:

  • RPh or Pharm.D. with active, unrestricted Pharmacist license in state of residence.
  • Drug utilization review experience.
  • Medicare Part B and Part D Coverage Determinations and member appeals experience.
  • Ability to foster a collaborative and high-performance work environment that promotes teamwork, innovation, and continuous improvement of member and provider experiences.
  • Ability to work with multiple software computer programs and applications in MS Office programs, including MS Teams.
  • Excellent written and oral communication abilities; clear, concise, and thorough documentation skills.
  • Flexibility and willingness to adjust to shifting demands/priorities.

Salary Range: $129,000-139,000 per year. Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Equal opportunity employer.


Assigned Work Hours:

On call and after hours availability required.

Position Type:


Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

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