Clinical Pharmacist (Pulse PBM)

Revive; Ponte Vedra Beach (FL); Vor Ort; USD 110.000 - 160.000; Vollzeit

Zusammenfassung

Revive Health is seeking a Clinical Pharmacist to join Pulse PBM, focusing on benefit design, cost containment, and clinical outcomes. You will partner with plan sponsors, brokers, and Revive leadership to implement, manage, and optimize pharmacy benefits, review claims in real time, and communicate with members and prescribers.

Requirements include a PharmD, active license, and at least 1 year in PBM/managed care or clinical pharmacy, with strong analytical and communication skills.

Qualifikationen

• Doctor of Pharmacy (PharmD) from ACPE-accredited college.
• Active, unrestricted pharmacist license; ability to obtain other licenses as needed.
• 1+ year pharmacist experience in PBM/managed care or clinical setting.
• Knowledge of formulary management, utilization management, prior authorization, and specialty pharmacy.
• Understanding PBM economics (net cost, rebates, pricing) and cost containment programs.
• Strong analytical skills including claims data with Excel; BI tools helpful.

Aufgaben

• Lead client implementations and guide benefit design decisions.
• Translate client decisions into clinical edits, prior authorization criteria, and step therapy rules.
• Review and optimize real-time PBM claims; identify cost savings opportunities.
• Suggest therapeutic interchanges, generics, and lower-net-cost options while maintaining outcomes.
• Prepare client reports and participate in quarterly business reviews.
• Maintain confidential documentation and ensure HIPAA/compliance.

Kenntnisse

Analytical skills

Written and verbal communication

Attention to detail

PBM economics knowledge

Reporting & data analysis

Ausbildung

Doctor of Pharmacy (PharmD)

Tools

Excel

BI tools

Jobbeschreibung

About Us

Revive is a dynamic and innovative organization specializing in healthcare delivery and technology. We pride ourselves on delivering exceptional products/services and building strong, long-lasting relationships with our valued clients.

Description

The Clinical Pharmacist is the clinical voice of Pulse PBM, Revive Health's pharmacy benefit management business. This role partners with plan sponsors, brokers, and Revive pharmacy leadership to design, implement, and manage pharmacy benefits that deliver the lowest net cost while protecting and improving member outcomes. The Clinical Pharmacist reviews claims in real time, recommends therapeutic interchanges and other clinical savings opportunities, runs Pulse's cost containment programs, produces client reporting, and is part of the team that communicates directly with members, prescribers, and clients, including at quarterly business reviews.

Duties

Client Implementation & Benefit Design

• Serve as the clinical lead on new client implementations, guiding plan sponsors and brokers through benefit design decisions such as formulary selection, utilization management, preventive coverage, and clinical program options.
• Review completed benefit design questionnaires and translate client decisions into clinical edits, prior authorization criteria, step therapy, and quantity limits in the claims system.
• Analyze prior-PBM claims and formulary data to assess member disruption, and recommend transition-of-care strategies before go-live.

Real-Time Claims Review & Clinical Optimization

• Monitor pharmacy claims in real time to identify high-cost claims, inappropriate utilization, safety concerns, and savings opportunities.
• Recommend therapeutic interchanges, generic and biosimilar alternatives, and other lower-net-cost options that maintain or improve clinical outcomes, and coordinate with prescribers and members to put changes in place.
• Analyze clinical reviews for prior authorizations, formulary exceptions, and coverage determinations according to plan criteria and render opinions or change recommendations.
• Conduct prospective, concurrent, and retrospective drug utilization review, and identify adherence and safety interventions such as opioid safety.

Cost Containment Programs

• Manage and execute Pulse cost-containment programs, including, but not limited to, international pharmacy, 340B, and manufacturer patient assistance programs.
• Identify eligible members and medications, coordinate enrollment, and track program savings and member impact.
• Ensure programs operate in line with plan documents, applicable federal and state law, and manufacturer program terms.

Reporting & Analytics

• Generate clinical and financial reports for clients and internal leadership, covering utilization trends, cost drivers, specialty spend, program savings, and clinical outcomes.
• Analyze claims data to project trend and quantify the impact of recommended benefit or formulary changes.
• Prepare clinical content for and participate in quarterly business reviews with clients and brokers.

Client & Member Communication

• Act as a clinical point of contact for plan sponsors, brokers, TPAs, and members, responding to clinical and coverage questions promptly and professionally.
• Communicate with members and prescribers about therapy changes, program enrollment, and coverage decisions in clear, plain language.
• Draft member and client communications such as formulary change notices and program materials.

Collaboration & Strategy

• Work closely with Revive pharmacy executives on clinical strategy, formulary management, pricing, and new program development.
• Partner with account management, operations, and the claims processor to resolve issues and improve workflows.
• Stay current on new drug approvals, the drug pipeline, guideline changes, and market events such as biosimilar launches and patent expirations, and advise on their impact to clients.

Quality Assurance & Compliance

• Maintain accurate documentation of clinical reviews, interventions, and program activity.
• Ensure work complies with HIPAA, ERISA, the ACA, state pharmacy regulations, and internal policies.

Requirements

• Doctor of Pharmacy (PharmD) from an ACPE-accredited college of pharmacy.
• Active, unrestricted pharmacist license in good standing, with the ability to obtain additional state licenses as required.
• Minimum of 1 year of pharmacist experience in a PBM, managed care, health plan, or clinical pharmacy setting; managed care residency (PGY1) or board certification is a plus.
• Working knowledge of formulary management, utilization management, prior authorization criteria, and specialty pharmacy.
• Understanding of PBM economics (net cost, rebates, pricing, and pass-through models) and cost containment programs such as copay maximizer, 340B, and patient assistance programs.
• Strong analytical skills, including working with claims data and advanced Excel; experience with reporting or BI tools is a plus.
• Excellent written and verbal communication skills, with the ability to present to clients, brokers, and executives.
• Attention to detail and the ability to manage multiple clients, deadlines, and priorities in a fast-paced environment.