Clinical Pharmacist

Western Health Advantage•Sacramento, CA

8d•Hybrid

About The Position

At Western Health Advantage, we are committed to delivering high-quality, clinically sound, and member-focused healthcare solutions. As a Clinical Pharmacist supporting Prior Authorization Operations, you will play a vital role in ensuring safe, effective, and compliant medication use across our member population. This role offers a unique opportunity to apply your clinical expertise in a managed care environment—supporting coverage determinations, influencing formulary strategy, and collaborating with cross-functional teams to improve outcomes and optimize care.

Requirements

Doctor of Pharmacy (PharmD) or equivalent required
Active, unrestricted California Pharmacist license in good standing
Minimum 4 years of pharmacy experience (retail, hospital, or mail order)
Experience with prior authorization review and utilization management
Proficiency in evaluating clinical literature and drug databases (e.g., UpToDate, DrugDex, NCCN)
Strong computer skills including Microsoft Office and pharmacy systems

Nice To Haves

2+ years of managed care, PBM, or health plan experience preferred
Familiarity with formulary management and P&T committee processes preferred

Responsibilities

Perform comprehensive clinical reviews of prior authorization (PA), exception, and appeal requests—leveraging clinical guidelines, drug information resources, and regulatory standards to ensure accurate and timely coverage determinations.
Apply and uphold all applicable regulatory and accreditation standards (NCQA, DMHC, Board of Pharmacy, Knox-Keene), ensuring that all decisions and processes meet compliance requirements and organizational policies.
Serve as a clinical resource to internal teams and network providers—clearly communicating decision rationale, supporting appeals, and contributing to pharmacy-related initiatives across the organization.
Contribute to formulary development and maintenance, provide clinical input on PBM strategies and P&T committee outputs, and support updates to prior authorization criteria and preferred drug lists.
Participate in workflow optimization, quality improvement initiatives, and system enhancements—helping to improve efficiency, reduce errors, and strengthen overall pharmacy operations.
Review and evaluate prior authorization requests for outpatient and specialty medications.
Conduct drug utilization reviews in compliance with regulatory standards.
Research and apply current clinical data and therapeutic guidelines.
Support appeals and grievance processes related to pharmacy benefit determinations.
Collaborate with PBM partners on formulary management and drug product updates.
Monitor and update formulary listings and PA criteria.
Analyze pharmacy trends and support cost-of-care initiatives.
Provide education to providers and internal stakeholders on pharmacy programs.
Assist with regulatory audits (DMHC, NCQA) and accreditation activities.
Support training, documentation, and process development initiatives.
Participate in system testing, validation, and operational readiness efforts.
Provide cross-coverage support and ensure timely case completion.