Pharmacist Clinical Senior - CarelonRx

Elevance Health•Atlanta, OH

7d•Hybrid

About The Position

CarelonRx is a proud member of the Elevance Health family of companies. CarelonRx pairs a strong, clinical-first lens with deep pharmacy expertise to create solutions that improve outcomes, control costs, and enhance each member’s health. The Pharmacist Clinical Senior will be responsible for developing and implementing pharmacy programs. This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

Requirements

Requires a BA/BS in Pharmacy.
Minimum of 4 years of experience as a pharmacist in a clinical setting; or any combination of education and experience, which would provide an equivalent background.
Requires a registered pharmacist.
Current unrestricted Pharmacist license in applicable state(s) required.
Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel, or any embassy located in or outside of the US, unless they are command-sanctioned activities.

Nice To Haves

PharmD preferred.
Demonstrated experience with pharmacy claims processing/adjudication logic and the ability to translate clinical intent into operational outcomes (e.g., PA, step therapy, quantity limits, DUR messaging, plan/benefit rule behavior).
Proven ability to perform claims configuration/build support (including non-standard or exception configurations), partnering effectively with IT/operations/coding teams to implement, test, and validate expected claim results.
Working knowledge of Medicaid/state program requirements (e.g., state PDL/drug list management, coverage rules, effective dating, compliance documentation) and experience operationalizing those requirements in claims and/or PA systems.
Strong requirements documentation skills—able to produce clear build specifications and decision logic in Excel and/or PDF (e.g., traceability from policy → configuration, test scenarios, effective dates), with disciplined version control.
For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
For associates working within Puerto Rico who are member or patient-facing either in a clinical setting or in the Best Transportation unit, a current PR health certificate and a current PR Law 300 certificate are required for this position.

Responsibilities

Provides clinical consulting services to clients, Sales, and Account Management and responsible for the implementation of clinical requirements and programs.
Leads configuration and customization of formulary and utilization management that align with client intent.
Communicates Pharmacy and Therapeutics (P&T) committee decisions as well as their impact on a client’s formulary.
Leads pharmacy claims adjudication configuration by translating formulary and utilization management requirements into claims processing rules/edits (including non-standard configurations), developing build specifications, and partnering with operations/coding teams to implement and validate expected claim outcomes.
Interprets and operationalizes Medicaid/state requirements (e.g., state drug lists, coverage rules, and PA requirements) by creating clear clinical criteria and configuration documentation for PA and claims systems; provides independent oversight to ensure consistent, compliant program setup.
Experience developing, maintaining, and communicating Prior Authorization clinical criteria in a format that can be operationalized by PA teams and configured in UM platforms; strong attention to clarity, consistency, and auditability.
Demonstrated strength in cross-functional collaboration (clinical, PBM/claims operations, PA operations, coding/IT, compliance) with the ability to resolve ambiguity and drive decisions to closure.
Ability to work independently, manage multiple concurrent initiatives, and prioritize effectively in a fast-changing environment with minimal supervision.
Experience coaching/mentoring other pharmacists or analysts, providing guidance on formulary/UM edits, claims outcomes, and documentation standards to ensure consistent, high-quality delivery.
Strong analytical and troubleshooting skills, including the ability to interpret claims outputs/reject messaging and related data extracts to identify root cause and recommend corrective action.