Senior Clinical Pharmacist

CenCal Health•Santa Barbara, CA

53d•$174,547 - $261,821

About The Position

The Senior Clinical Pharmacist provides advanced clinical and operational support for CenCal Health’s pharmacy programs. This role supports the pharmacy team in maintaining high-quality, compliant pharmacy services across all lines of business. Responsibilities include: Clinical Pharmacy Programs Drug Utilization Review (DUR) and Clinical Initiatives Utilization Management and Authorization Reviews Departmental and Cross Functional Support

Requirements

Strong knowledge of clinical therapeutics, managed care principles, drug utilization, evidence-based medicine, and appropriate medication use.
Working knowledge of Medi-Cal and Medicare Part B and Part D programs, including UM regulations formulary management, and MTM requirements.
Ability to analyze pharmacy and claims data, identify trends, and interpret reporting metrics.
Ability to communicate effectively, both orally and in writing, to members, providers, and internal stakeholders.
Ability to maintain accurate documentation and manage multiple systems and software applications.
Doctor of Pharmacy (Pharm.D.) degree
Active California pharmacist license in good standing.
Minimum of four (4) years of managed care experience strongly preferred.

Nice To Haves

Knowledge of managed care and formulary benefit design.
Experience in staff supervision, workflow development, or cross-functional activities is desirable.

Responsibilities

Develops, implements, and maintains clinical pharmacy programs for all lines of business, including MTM, medication adherence, and disease state management.
Contributing to the design and implementation of pharmacy programs that support organizational goals, medication-related quality measures (e.g., Star Ratings), and member experience.
Evaluating and refining workflows to maintain program effectiveness and efficiency.
Collaborating with Quality Improvement and Population Health teams to support medication-related quality initiatives.
Supporting interventions to improve medication adherence, safety, and clinical outcomes.
Monitoring delegated vendors and PBM activities through required reports and routine oversight.
Assisting with PBM delegate and subdelegate oversight to ensure compliance with Medicare, Medi-Cal, accreditation standards, and internal policies.
Overseeing and supporting MTM activities in partnership with the PBM, including CMRs, targeted reviews, chart review, and communication with members and prescribers.
Maintains the DUR program and supports plan-wide clinical initiatives.
Conducting prospective, concurrent, and retrospective DUR reviews in compliance with Medi-Cal, Medicare, and internal standards.
Utilizing plan and PBM systems to identify utilization trends, safety concerns, potential misuse, and opportunities for intervention.
Maintaining and updating the plan’s DUR dashboard.
Developing provider-facing educational materials, drug alerts, and clinically focused communication.
Supporting disease-management and care-coordination programs by providing pharmacy-related clinical insight.
Performs and supports the medication coverage determination process to ensure appropriate clinical decision-making and regulatory compliance.
Conducting UM reviews using established policies, clinical criteria, Medicare/Medi-Cal regulations, and benefit coverage rules (including physician-administered drugs).
Ensuring timeliness and accuracy of coverage determinations, redeterminations, and appeals in accordance with CMS requirements.
Assisting in the development and maintenance of pharmacy criteria, UM workflows, and decision-support documents.
Supporting the annual pharmacist inter-rater-reliability (IRR) process.
Participating in the Pharmacy & Therapeutics (P&T) Committee and Subcommittee activities, including preparation of materials and reports.
Reviewing drug utilization and claim trends to inform cost-effective benefit design recommendations.
Responding to grievances, appeals, and inquiries related to the pharmacy benefit and collaborating with the Grievance & Appeals team as needed.
Supporting oversight of PBM-delegated UM functions, including validation of PBM performance and documentation accuracy.
Supports pharmacy initiatives aimed at improving operational performance, quality measures, and member outcomes.
Assists with regulatory reporting, including CMS and DHCS submissions.
Supports internal and external audits through data validation, documentation review, and follow-up.
Collaborates with Operations, Compliance, Quality, Care Coordination, IT, and other departments to advance pharmacy-related initiatives.
Participates in special projects and other duties as assigned to support the Pharmacy Director and departmental operations.