Clinical Programs Pharmacist
About The Position
The Clinical Pharmacist will receive direction from the Sr. Director of Pharmacy Solutions to support the development, implementation, and oversight of clinical programs. This position is responsible for reviewing and adjudicating prior authorization requests, developing and maintaining evidence-based clinical criteria, and serving as a clinical resource for pharmacy technicians and cross-functional teams. The role ensures safe, appropriate, and cost-effective medication use while aligning with client benefit design and regulatory requirements. They will assist in the communication between members, brokers, HR, and their direct report needed to ensure retention and operational excellence.
Requirements
- Doctor of Pharmacy (PharmD)
- Active, unrestricted pharmacist license in good standing
- 2+ years of clinical pharmacy experience (managed care, PBM, specialty, or retail)
- Strong knowledge of utilization management tools (PA, step therapy, quantity limits)
- Strong clinical judgment and analytical skills
- Ability to balance clinical appropriateness with financial stewardship
- Excellent written documentation skills
- Detail-oriented with strong time management abilities
- Ability to work collaboratively across clinical and operational teams
- Ability to balance clinical appropriateness with financial stewardship
- Strategic thinker who can move between individual case review and population-level impact
Nice To Haves
- Experience reviewing prior authorizations
- Experience developing clinical criteria
Responsibilities
- Review and provide oversight of complex or escalated prior authorization requests
- Document clinical determinations clearly and accurately
- Participate in peer-to-peer discussions when necessary
- Develop and maintain evidence-based prior authorization criteria, step therapy protocols, and quantity limits
- Ensure alignment between clinical guidelines, plan documents, and operational execution
- Identify opportunities to enhance clinical rigor while maintaining operational efficiency
- Assist in formulary evaluation and design recommendations
- Evaluate clinical and financial impact of new brand and generic launches
- Monitor therapeutic class changes, pipeline drugs, and specialty trend drivers
- Support clinical discussions and clinical program recommendations
- Serve as a clinical subject matter expert for pharmacy technicians and operations teams
- Provide guidance on complex medication cases and high-cost therapies
- Assist with training on criteria updates and program enhancements
- Performs other duties as assigned
- Partner with PBM clinical teams to ensure accurate execution of criteria
- Review PBM performance metrics related to prior authorization and utilization management
- Assist in identifying gaps or inconsistencies in PBM clinical application
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Ph.D. or professional degree
