Clinical Pharmacy - Utilization Management Clinical Pharmacist PC#146-2002

CommunityCare, Inc.; Tulsa (OK); Remote; USD 120,000 - 150,000; Full time

Job summary

CommunityCare, Inc. is seeking an Utilization Management Clinical Pharmacist to optimize medication use, support formulary development, and ensure compliance across medical injectable and specialty therapies.

The role emphasizes evidence-based care, cost-conscious decisions, and collaboration with clinicians to improve member outcomes. The position requires PharmD or BS in Pharmacy, an active US license, and at least five years in managed care or PBM settings, with experience in prior

Qualifications

• Requires strong knowledge of managed care pharmacy, utilization management and formulary management.
• Understanding of Medicare, Commercial and PBM operations.
• Ability to interpret clinical literature, guidelines, and regulations.
• Strong analytical, organizational, and decision-making skills.
• Excellent written, verbal, and presentation abilities.
• Ability to collaborate across multidisciplinary teams.
• Proficiency with Microsoft Office and pharmacy IT systems.
• Remote work eligibility for qualified candidates.
• On-call coverage on weekends/holidays on a rotating schedule.
• Successful completion of Health Care Sanctions background check.

Responsibilities

• Review prior authorization requests for medical injectable and specialty meds using evidence-based criteria.
• Approve or deny requests within established turnaround times.
• Collaborate with technicians, medical directors, and clinicians to support UM decisions.
• Provide clinical consultation on complex requests and coverage determinations.
• Support development and maintenance of medical drug utilization management programs.
• Develop clinical criteria, policies and prior authorization guidelines.
• Perform annual policy reviews updating criteria with new evidence and guidelines.
• Monitor new drug approvals and suggest UM strategies.
• Create educational materials for providers and internal stakeholders.
• Participate in provider outreach and detailing on evidence-based prescribing and formulary optimization.
• Support newsletters and clinical training initiatives.
• Perform other related duties as required.

Skills

Managed care pharmacy

Utilization management

Formulary management

Clinical decision making

Medicare PBM knowledge

Communication skills

Microsoft Office

Pharmacy information systems

On-call coverage

Education

PharmD or BS in Pharmacy

Active pharmacist license in US

5+ years clinical pharmacy experience

Experience reviewing prior authorization for medical injectable and specialty meds (Medicare Part D/Commercial)

Job description

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.
• 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.
• Active, unrestricted pharmacist license in any United States jurisdiction.
• 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.