PBM Clinical Pharmacist: Real-Time Claims & Savings

Guide+Thrive; United States; On-site; USD 100,000 - 125,000; Full time

Job summary

Revive Health is seeking a Clinical Pharmacist to serve as the clinical voice of Pulse PBM, Revive Health's pharmacy benefit management business. You will design and manage pharmacy benefits, review claims in real time, and implement cost containment programs to lower net costs while protecting patient outcomes.

You will collaborate with plan sponsors, brokers, and Revive leadership to deliver client reporting and support quarterly business reviews, ensuring compliance with HIPAA and ERISA

Qualifications

• Doctor of Pharmacy (PharmD) from ACPE-accredited college of pharmacy.

Responsibilities

• 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.
• 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.
• Manage and execute Pulse cost containment programs, including copay maximizer, 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.
• 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.
• 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.
• 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.
• Maintain accurate documentation of clinical reviews, interventions, and program activity.
• Ensure work complies with HIPAA, ERISA, the ACA, state pharmacy regulations, and internal policies.

Skills

Pharmacist knowledge

Advanced Excel

PBM understanding

Formulary management

Utilization management

Education

Doctor of Pharmacy (PharmD)

Active pharmacist license

Tools

Excel

Job description

Revive Health is seeking a Clinical Pharmacist to serve as the clinical voice of Pulse PBM, Revive Health's pharmacy benefit management business. You will design and manage pharmacy benefits, review claims in real time, and implement cost containment programs to lower net costs while protecting patient outcomes.

You will collaborate with plan sponsors, brokers, and Revive leadership to deliver client reporting and support quarterly business reviews, ensuring compliance with HIPAA and ERISA