PHARMACIST

Paycom - ATS; Sacramento (CA); On-site; USD 155,000 - 170,000; Full time

Job summary

Paycom - ATS is seeking an experienced pharmacist to oversee utilization review and benefit administration within a managed care setting in California. The role focuses on ensuring appropriate, cost-effective medication use, MTM and transitions of care for high-risk members, and supporting coverage determinations.

The ideal candidate holds a PharmD, is licensed in California, and has 3–5 years of clinical pharmacy experience, with knowledge of Medi-Cal and Medicare Part D.

Qualifications

• Minimum 3–5 years of clinical pharmacy experience.
• Experience in managed care, health plan operations, or population health management preferred.
• Knowledge of Medi-Cal and Medicare Part D programs and regulations.

Responsibilities

• Conduct daily review of outpatient requests using applicable criteria to ensure cost-effective medication use.
• Support coverage determinations, appeals, and documentation as needed.
• Perform MTM, CMRs, and TMRs for high-risk or prioritized members.
• Conduct transitions of care and post-discharge reconciliation for select patients.
• Assist in QA, population health initiatives, and performance reporting.

Skills

Clinical pharmacy

Managed care

Medicare/Medicaid (Medi-Cal)

MTM & CMRs

Pharmacy analytics

Education

PharmD (Doctor of Pharmacy)

CA Pharmacist license

Board certification (BCPS/BCACP)

Tools

Pharmacy information systems

Electronic Health Records

Job description

Job Details: Job Location: SACRAMENTO, CA 95831, Position Type: Full Time, Education Level: Graduate Degree, Salary Range: $155,000.00 - $170,000.00 Salary, Travel Percentage: Negligible, Job Shift: Day, Job Category: Health Care, Job Summary:

Responsibilities

Utilization Review & Benefit Administration

• Conduct daily review of outpatient PAs, TARs, and specialty drug requests using Medi-Cal, Medicare, and Vivant Health criteria.
• Apply formulary guidelines, step therapy, and evidence-based standards to ensure appropriate, cost-effective medication use.
• Provide therapeutic alternatives and recommendations for non-formulary requests.
• Support coverage determinations, appeals, and documentation as needed.
• Comprehensive medication management (MTM, CMRs, TMRs) performed on a targeted basis—focused on high-risk or plan-prioritized members.
• Transitions of care and post-discharge medication reconciliation for select high-risk cases referred through care management.
• Patient counseling and disease state self-management support provided as brief, case-based interventions rather than ongoing longitudinal education.
• Prior Authorization Review – Supporting Vivant Health in reviewing prior authorization requests as the primary UM workload.
• Pharmacy Claims Review performed for targeted cases (new drugs, outliers, or flagged claims) rather than universal claim review.
• High-Utilization Specialties reviewed only when flagged for clinical appropriateness or financial impact (e.g., oncology, rheumatology, dermatology).

Quality Management & Performance Improvement

• Support priority Star Ratings and HEDIS pharmacy measures, with an emphasis on medication adherence and access barriers.
• Collaborate with Population Health and Quality teams on select, high-impact, pharmacy-driven interventions.
• Population health initiatives, quality improvement, and performance reporting conducted on a scheduled, manageable cadence (e.g., monthly or quarterly reports).
• Medication Reconciliation & Adherence work performed through limited case review and provider collaboration on targeted patients.
• Participate in focused quality improvement activities aligned with the organization’s highest-priority pharmacy metrics.

Program Oversight, Compliance & Cost Analysis

• Ensure compliance with CMS, DHCS, NCQA, and URAC for pharmacy utilization management and documentation.
• Provide subject matter expertise during audits and accreditation events when pharmacy elements are reviewed.
• Cost Impact Analysis performed for selected high-cost or high-frequency therapies to support decision-making and trend reporting.
• Monitor for fraud, waste, and abuse through review of flagged cases rather than broad surveillance.

Interdisciplinary Collaboration & Clinical Leadership

• Serve as a medication management resource for clinical and care management teams as questions arise.
• Interdisciplinary case conferences and care coordination attended selectively—prioritizing cases where pharmacy input may meaningfully affect outcomes.
• Collaboration with providers on formulary management, drug utilization review, and prior authorizations conducted through scheduled communications or case-specific outreach.
• Provide internal education on UM criteria or pharmacy policies as needed (e.g., quarterly updates or targeted trainings).

Health Plan & External Partner Engagement

• Manage all pharmacy-related programs with California Northstate College of Pharmacy.
• Utilization Review with Health Plans by participating in scheduled meetings or case discussions related to pharmacy utilization.
• Provide input on discrepancies between provider requests and health plan criteria in a manageable, case-driven manner.
• Support provider education efforts during targeted outreach campaigns rather than broad trainings.

Other Functions

• Enforces Company policies and safety procedures.
• Regularly updates job knowledge by participating in educational opportunities, reading professional publications, maintaining professional networks, and participating in professional organizations.
• Maintain IPA, Health Plan compliance standards.
• Other duties as assigned.

Competencies

• Minimum 3-5 years of clinical pharmacy experience.
• Experience in managed care, health plan operations, or population health management preferred.
• Knowledge of Medi-Cal and Medicare Part D programs and regulations.
• Experience with MTM programs, prior authorization processes, and formulary management.
• Proficiency in pharmacy information systems and electronic health records.
• Strong analytical skills with experience in claims data analysis.
• Knowledge of clinical decision support tools and evidence-based medicine resources.
• Familiarity with quality measures (HEDIS, Medicare Stars, CAHPS).
• Strong clinical knowledge across therapeutic areas.
• Excellent communication (both oral and written) and interpersonal skills.
• Ability to work collaboratively in interdisciplinary teams.
• Strong problem-solving and critical thinking abilities.
• Attention to detail and ability to manage multiple priorities.
• Knowledge of regulatory requirements and compliance standards.
• Excellent active listening and critical thinking and analytical skills.
• Demonstrate leadership skills and initiative.
• Ability to provide and receive constructive job and/or industry related feedback.
• Ability to exercise sound discretion and strict maintenance of confidentiality of all confidential and sensitive communications and information.
• Ability to consistently deliver excellent customer service.
• Excellent attention to detail and ability to document information accurately.
• Ability to effectively and positively work in a dynamic, fast-paced team environment and achieve objectives.
• Demonstrate commitment to the organization’s mission.
• Must have mid-level skills in Microsoft software (Word, Excel, PowerPoint, Visio) and Access is a plus.
• Typing speed of 40 wpm or more is a plus.
• Must have the ability to quickly learn and use new software tools.
• Must have mid-level skills using e-mail applications.
• Ability to work independently as well as in a team environment.
• Ability to present self in a professional manner and represent the Company image.

Education and Licensure

• Doctor of Pharmacy (PharmD) degree from an accredited program.
• Active California pharmacist license in good standing.
• Board certification (BCPS, BCACP, or relevant specialty) preferred.