Clinical Pharmacy Consultant (PBM/BPO Required)

Optum, a UnitedHealth Group Company; Makati; On-site; PHP 600,000 - 1,200,000; Full time

Benefits offered by this job

Market competitive pay levels

Retirement plan

Medical plan (HMO) from Day 1

Dental, medical, and optical reimburse

Life and disability insurance

Paid time-off benefits

Sick leave conversion

Tuition fee reimbursement

Employee assistance program (EAP)

Merit increases

Employee recognition

Training and staff development

Employee referral program

Volunteerism opportunities

All statutory benefits

Job summary

Optum, a UnitedHealth Group company, seeks a Clinical Pharmacist on the Clinical Coding Consulting team in Makati. You will bridge Formulary & Utilization Operations with Clinical Consultants and BOM, delivering coding guidance and support for formulary setups in RxClaim and related apps.

You will perform pharmacology and coding analyses, support client implementations, and translate business needs into codable solutions while collaborating with internal teams.

Qualifications

• Bachelor of Science in Pharmacy (BS Pharmacy) or Doctor of Pharmacy (PharmD).
• Must be a Licensed Pharmacist.
• 2–5 years of pharmacy-related experience in PBM/healthcare settings.
• Strong understanding of PBM concepts, formulary management, and utilization management.
• Experience conducting pharmacy claims research, coding analysis, and issue resolution.
• Experience using RxClaim or other pharmacy claims adjudication systems preferred.
• Strong analytical, problem-solving, communication, and stakeholder management skills.
• Intermediate to advanced Microsoft Excel proficiency.
• Proficient in MS Office and Windows environments.
• Ability to translate business and client requirements into coding solutions.

Responsibilities

• Provide consultative guidance for standard and custom formulary changes in RxClaim, RxBuilder, and related apps.
• Conduct second-level formulary and utilization management claim research.
• Provide implementation clinical coding support for BDS, cBDT, RxConstruct inquiries.
• Support GPI reclassifications and global coding changes.
• Provide commercial clinical audit support.
• Manage custom formulary coding work after client sign-off.
• Translate client intent into codable language for BOM team.
• Evaluate and resolve new rule designs and conflicts in formulary coding.
• Support new client implementations involving custom formulary programs.
• Extract, evaluate, and interpret clinical coding within adjudication systems.

Skills

Pharmacist license

PBM knowledge

Excel proficiency

Communication skills

Stakeholder mgmt

Clinical coding

RxClaim experience

RxBuilder/RxAuth familiarity

Education

BS Pharmacy or PharmD

Tools

RxClaim

RxBuilder

RxAuth

RxInteract

Job description

The Clinical Pharmacist on the Clinical Coding Consulting team serves as the primary liaison between OptumRx's Formulary & Utilization Operations, Benefit Operations Management, and the Clinical Consultant. The role provides clinical coding support for OptumRx clinical consultants, benefit operations management (BOM), information technology, and other internal departments. This individual is relied upon to provide custom formulary and utilization management coding consultation and support to client-facing clinical consultant teams on formulary and utilization management setup in the RxClaim adjudication system and related formulary management applications.

Primary Responsibilities

• Provide consultative guidance for standard and custom formulary changes in RxClaim, RxBuilder, and related clinical applications (RxAuth, RxInteract).

• Conduct second-level Formulary and Utilization Management claim research.

• Provide implementation clinical coding support for BDS, cBDT, and RxConstruct inquiries.

• Support GPI reclassifications, global coding changes, and drug utilization management initiatives.

• Provide commercial clinical audit support.

• Manage custom formulary coding work following client sign-off.

• Translate client intent into codable language for the Benefit Operations Management team.

• Evaluate and resolve new rule designs and conflicts with existing formulary coding.

• Support new client implementations involving custom formulary and utilization management programs.

• Extract, evaluate, and interpret clinical coding within adjudication and formulary management systems.

Required Qualifications

• Bachelor of Science in Pharmacy (BS Pharmacy) or Doctor of Pharmacy (PharmD).

• Must be a Licensed Pharmacist.

• Minimum of 2 to 5 years of pharmacy-related experience, preferably within a Pharmacy Benefit Management (PBM), healthcare BPO, shared services, managed care, healthcare operations, retail pharmacy, or hospital pharmacy environment.

• Strong understanding of Pharmacy Benefit Management (PBM) concepts, pharmacy benefit operations, formulary management, utilization management, clinical coding, or benefit administration.

• Experience conducting pharmacy claims research, coding analysis, investigation, and issue resolution.

• Experience utilizing RxClaim or other pharmacy claims adjudication systems is preferred.

• Strong analytical, problem-solving, communication, and stakeholder management skills.

• Intermediate to advanced proficiency in Microsoft Excel.

• Proficient in Microsoft Office applications and Windows-based environments, including Microsoft Word, Outlook, and internet research.

• Ability to translate business and client requirements into operational and coding solutions.

Preferred Qualifications

• Experience supporting U.S. healthcare, pharmacy benefits, claims operations, or clinical pharmacy services in a PBM or healthcare BPO setting.

• Strong preference for candidates with pharmacy experience gained in a PBM, healthcare BPO, shared services, retail pharmacy, or hospital pharmacy environment.

• Experience in Clinical Consulting, Clinical Pharmacy, Formulary Management, Utilization Management (UM), or Benefit Administration.

• Subject Matter Expert (SME) or Team Lead (TL) experience in a Pharmacy, PBM, or healthcare BPO environment is highly desirable.

• Combination of Pharmacy credentials and PBM/BPO experience is highly preferred.

Work Schedule and Setup

• Must be amenable to working onsite in Makati for approximately 6 to 8 weeks during training.

• Transition to a hybrid work arrangement after training, subject to business needs and performance requirements.

• Must be available to work a fixed night shift schedule of 9:00 PM to 6:00 AM.

• Candidates who are immediately available or can start as soon as possible are highly preferred.

WHAT WE OFFER

• Market Competitive Pay Levels

• Retirement Plan

• Medical Plan (HMO) from Day 1 of employment

• Dental, Medical, and Optical Reimbursements

• Life and Disability Insurance

• Paid Time-Off Benefits

• Sick Leave Conversion

• Tuition Fee Reimbursement

• Employee Assistance Program (EAP)

• Annual Performance Based Merit Increases

• Employee Recognition

• Training and Staff Development

• Employee Referral Program

• Employee Volunteerism Opportunity

• All Mandatory Statutory Benefits

WHO WE ARE

• Optumis the health care technology and innovation company of the UnitedHealth Group enterprise along with UnitedHealthcare.

• UnitedHealth Groupis a health care and well-being company with a mission to help people live healthier lives and help make the health system work better for everyone.

• We’re a leading health solution and care delivery organization. Our work is complex, but our mission is simple: create a healthier world, with you at the center.

• As part of a Fortune 5 enterprise, we are improving the health care experience of over 125 million people around the world.

• Elevate your career with a leading health care company while improving lives.

Join us in evolving health care so everyone can have the opportunity to live their healthiest life. This is your opportunity to be part of a team that’s dedicated to Caring. Connecting. Growing together.