Clinical Pharmacist - Managed Care & UM (Hybrid)

ACTalent; Sacramento (CA); Hybrid; USD 101,000 - 110,000; Full time

Benefits offered by this job

Medical benefits

Dental & Vision benefits

Critical Illness, Accident & Hospital

401(k) plan

Life Insurance

Disability insurance

HSA

Transportation benefits

Employee Assistance Program

Paid time off

Job summary

ACTalent is seeking an experienced Clinical Pharmacist to support managed care operations with emphasis on utilization management, prior authorization review, formulary management, and MTM. The role collaborates with providers, health plans, care teams, and stakeholders to promote appropriate medication use, improve outcomes, and manage costs in a health-plan environment.

Ideal candidates bring CA Pharmacist license, PharmD, 3–5 years of clinical pharmacy experience in managed care, and strong

Qualifications

• Doctor of Pharmacy (PharmD) degree from an accredited program.
• Active California Pharmacist License in good standing.
• 3–5 years of clinical pharmacy experience.
• Experience in managed care, health plan operations, PBM, Medicare Advantage, Medi-Cal, Medicaid, or population health settings.
• Experience with: Utilization Management (UM)
• Prior Authorization (PA)
• Formulary Management
• Medication Therapy Management (MTM)
• Clinical guideline review
• Strong analytical and problem-solving skills.
• Excellent verbal and written communication skills.
• Proficiency with Microsoft Office and clinical/pharmacy information systems.

Responsibilities

• Review outpatient prior authorization requests and specialty medication requests using established clinical guidelines and coverage criteria.
• Evaluate medication appropriateness, formulary compliance, step therapy requirements, and therapeutic alternatives.
• Support coverage determinations, appeals, and clinical documentation processes.
• Conduct MTM, CMRs, TMRs, medication reconciliation, and adherence interventions.
• Review high-cost therapies, specialty medications, and pharmacy claims data to identify utilization and cost-management opportunities.
• Support transitions of care and medication optimization initiatives.
• Support medication-related quality initiatives, including HEDIS and Medicare Star Ratings measures.
• Collaborate with Quality, Care Management, and Population Health teams to improve medication adherence and health outcomes.
• Participate in quality improvement projects, performance monitoring, and program evaluations.
• Maintain compliance with regulatory, accreditation, and organizational requirements.
• Support pharmacy audits, accreditation activities, and UM documentation standards.
• Assist in identifying opportunities to improve medication effectiveness, safety, and cost-efficiency.
• Review cases for potential fraud, waste, and abuse.
• Serve as a pharmacy SME for clinical and operational teams.
• Partner with providers and health plans regarding prior authorizations, formulary management, utilization reviews, and medication-related policies.
• Participate in interdisciplinary meetings, case reviews, and provider education initiatives.
• Provide training and education regarding pharmacy programs, utilization criteria, and regulatory updates.

Skills

Pharmacist license

Clinical pharmacy experience

Managed care exposure

UM

PA

Formulary management

MTM

Clinical guidelines

Communication skills

MS Office & pharmacy systems

Education

PharmD

Job description

ACTalent is seeking an experienced Clinical Pharmacist to support managed care operations with emphasis on utilization management, prior authorization review, formulary management, and MTM. The role collaborates with providers, health plans, care teams, and stakeholders to promote appropriate medication use, improve outcomes, and manage costs in a health-plan environment.

Ideal candidates bring CA Pharmacist license, PharmD, 3–5 years of clinical pharmacy experience in managed care, and strong