Clinical Pharmacist, Managed Care & Outcomes

Vivant Health; Sacramento (CA); Vor Ort; USD 155.000 - 170.000; Vollzeit

Zusammenfassung

Vivant Health is seeking a Clinical Pharmacist to support managed pharmacy operations across Medicare Advantage and Medi-Cal, focusing on utilization management, prior authorization, formulary management, and specialty cost optimization. You will leverage clinical expertise and claims analytics to improve access, HEDIS/Star ratings, and population health outcomes.

Responsibilities include reviewing PAs, applying formulary criteria, supporting coverage determinations, MTM and medication

Qualifikationen

• 3–5 years of clinical pharmacy experience in managed care, health plan operations, or population health management.
• Experience with Medicare Advantage, Medi-Cal, and Medicare Part D.
• Expertise in utilization management, prior authorization, formulary management, MTM, and evidence-based clinical review.
• Experience with Pharmacy & Therapeutics (P&T) committee activities, including formulary evaluation and assessment of alternatives.
• Knowledge of CMS, DHCS, NCQA, URAC regulatory and accreditation requirements.
• Knowledge of HEDIS measures, Medicare Star Ratings, CAHPS, and population health initiatives.
• Strong analytical skills evaluating pharmacy claims, utilization trends, and total cost of care.
• Ability to collaborate with providers, health plans, and interdisciplinary teams.

Aufgaben

• Review outpatient prior authorizations (PAs) and specialty drug requests using Medi-Cal, Medicare, and Vivant Health criteria.
• Apply formulary requirements, step therapy, and evidence-based guidelines; recommend alternatives.
• Support coverage determinations, appeals, and clinical documentation.
• Conduct MTM, CMRs, TMRs, medication reconciliation, and adherence interventions for high-risk members.
• Review high-cost therapies and high-utilization specialties for cost impact and clinical appropriateness.
• Support transitions of care and brief patient counseling for selected cases.
• Collaborate on priority quality measures (HEDIS/Star) and participate in performance reporting.
• Ensure CMS, DHCS, NCQA, URAC compliance and participate in audits.

Kenntnisse

Utilization management

Prior authorization

Formulary management

MTM

Data analysis

Regulatory compliance

Communication skills

Collaboration

Ausbildung

Doctor of Pharmacy (PharmD)

Licensed pharmacist in CA

Board certification (BCPS/BCACP) preferred

Tools

MS Office

Pharmacy information systems

Jobbeschreibung

Vivant Health is seeking a Clinical Pharmacist to support managed pharmacy operations across Medicare Advantage and Medi-Cal, focusing on utilization management, prior authorization, formulary management, and specialty cost optimization. You will leverage clinical expertise and claims analytics to improve access, HEDIS/Star ratings, and population health outcomes.

Responsibilities include reviewing PAs, applying formulary criteria, supporting coverage determinations, MTM and medication