Clinical Pharmacy - Utilization Management Clinical Pharmacist 146-2005

CommunityCare HMO Inc.; Tulsa (OK); Remote; USD 110,000 - 150,000; Full time

Job summary

CommunityCare HMO Inc. seeks a Utilization Management Clinical Pharmacist to optimize medication use, support formulary development, and ensure regulatory compliance across medical injectable and specialty therapies.

You will review prior authorization requests, approve or deny within turnaround targets, and collaborate with pharmacy technicians, medical directors, and clinicians to drive evidence-based decisions.

Qualifications

• PharmD or PharmD-equivalent with Oklahoma licensure or eligible.
• Minimum five years in managed care or PBM settings.
• Experience reviewing prior authorization for medical injectable and specialty meds preferred.

Responsibilities

• Review prior authorization requests for medical injectable, specialty, and high-cost meds.
• Approve or deny requests within turnaround times while ensuring clinical appropriateness.
• Collaborate with technicians, medical directors, and clinicians on UM decisions.
• Provide clinical consultation on complex requests and determinations.
• Support development, implementation, and maintenance of UM programs.
• Develop and maintain evidence-based criteria, policies, and guidelines.
• Perform annual policy reviews and update criteria based on evidence and guidelines.
• Monitor new drug approvals and recommend UM strategies.
• Support MTM program and conduct Comprehensive Medication Reviews as needed.
• Perform pharmacy case management to identify problems and interventions.
• Develop educational materials for providers and internal stakeholders.
• Participate in provider outreach and academic detailing focused on evidence-based prescribing.
• Support provider newsletters, educational programs, and clinical training initiatives.
• Perform other related duties as required, including on-call coverage.

Skills

Managed care pharmacy

Utilization management

Formulary management

Medicare knowledge

Pharmacy benefit management

Clinical decision making

Communication skills

Collaboration

Microsoft Office

Pharmacy information systems

Education

PharmD or BS in Pharmacy

Tools

Pharmacy information systems

PBM software

Job description

Job Summary

The Utilization Management Clinical Pharmacist is responsible for playing a critical role in optimizing medication use, improving member outcomes, and ensuring regulatory compliance. This position serves as a clinical expert supporting medical injectable and specialty medication utilization management, formulary development, clinical policy creation, and all other clinical pharmacy initiatives as needed. This role helps ensure members receive safe, effective, evidence-based, and cost-conscious drug therapy while supporting organizational quality, compliance, and operational goals.

Key Responsibilities

• Review prior authorization requests for medical injectable, specialty, and other high-cost medications using evidence-based clinical criteria, regulatory requirements, and benefit design.
• Approve or deny medication requests within established turnaround time requirements while ensuring consistency and clinical appropriateness.
• Collaborate with pharmacy technicians, medical directors, and other clinicians to facilitate timely and accurate utilization management decisions.
• Provide clinical consultation regarding complex medication requests and coverage determinations.
• Support the development, implementation, and maintenance of medical drug utilization management programs.
• Develop and maintain evidence-based clinical criteria, treatment policies, and prior authorization guidelines.
• Perform annual policy reviews and update clinical criteria based on emerging evidence, clinical guidelines, and regulatory changes.
• Monitor new drug approvals and recommend appropriate utilization management strategies.
• Support Medication Therapy Management Program by conducting Comprehensive Medication Reviews (CMRs) and other activities as needed to support program and quality initiatives.
• Perform pharmacy case management which helps to identify medication-related problems and recommend evidence-based interventions to optimize therapy for identified members.
• Develop educational materials and clinical communications for providers and internal stakeholders.
• Participate in provider outreach and academic detailing initiatives focused on evidence-based prescribing and formulary optimization.
• Support provider newsletters, educational programs, and clinical training initiatives.
• Perform other related job duties as required or assigned.

Qualifications

• Strong knowledge of managed care pharmacy, utilization management, and formulary management principles.
• Demonstrated understanding of Medicare, Commercial, and pharmacy benefit management operations.
• Ability to interpret and apply clinical literature, treatment guidelines, and regulatory requirements.
• Strong analytical, organizational, critical thinking, and decision-making skills.
• Excellent written, verbal, and presentation skills.
• Ability to effectively collaborate across multidisciplinary teams.
• Proficiency with Microsoft Office applications and pharmacy information systems.
• Ability to work remotely will be provided to qualified candidates
• On call coverage for weekends and holidays necessary on a scheduled rotation
• Successful completion of Health Care Sanctions background check.

Education/Experience

• Doctor of Pharmacy (PharmD) or Bachelor of Science in Pharmacy from an accredited School of Pharmacy.
• Current, unrestricted pharmacist license in the State of Oklahoma, or ability to obtain Oklahoma licensure within 180 days of hire.
• A minimum of five years of clinical pharmacy experience in managed care pharmacy, health plan pharmacy, pharmacy benefit management, specialty pharmacy, hospital pharmacy, or a related clinical practice setting.
• Prior experience reviewing prior authorization requests for medical injectable and specialty medications with Medicare Part D and Commercial lines of business preferred.

CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin