Clinical Pharmacist Utilization Management - Aspire Health

Montage Health

2d

About The Position

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 is responsible for making accurate, evidence-based coverage determinations and appeal decisions, supporting pharmacy quality initiatives tied to CMS Star Ratings, and ensuring compliance with CMS regulations. The pharmacist functions in a highly cross-functional capacity, partnering with operations, quality, compliance, vendors, providers, and customer service teams to improve medication access, safety, adherence, and member experience across all lines of business.

Requirements

• Pharm.D. or RPh from an accredited School of Pharmacy.
• Active, unrestricted pharmacist license in California.
• Strong analytical, organizational, and written/verbal communication skills.

Nice To Haves

• Medicare Advantage Part B and Part D utilization management experience preferred.

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 appropriately 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 member issues and close care gaps.
• Complete interventions to improve biosimilar conversions across all lines of business.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level