Research and synthesize detailed clinical data related to pharmaceuticals
Serves as a clinical resource to other pharmacists on areas such as formulary, utilization management edits, DURs and coordinates with operations team to code programs to meet intent
Leads pharmacy claims adjudication configuration by translating formulary and utilization management requirements into claims processing rules/edits
Interprets and operationalizes Medicaid/state requirements by creating clear clinical criteria and configuration documentation for PA and claims systems; provides independent oversight to ensure consistent, compliant program setup

Requires a BA/BS in Pharmacy
Minimum of 2 years of managed care pharmacy (PBM) experience or residency in lieu of work experience; or any combination of education and experience, which would provide an equivalent background
Requires a registered pharmacist
Current unrestricted Pharmacist license in applicable state(s) required.
PharmD preferred
Demonstrated experience with pharmacy claims processing/adjudication logic and the ability to translate clinical intent into operational outcomes
Proven ability to perform claims configuration/build support
Working knowledge of Medicaid/state program requirements
Experience developing, maintaining, and communicating Prior Authorization clinical criteria
Strong requirements documentation skills
Demonstrated strength in cross-functional collaboration
Ability to work independently, manage multiple concurrent initiatives, and prioritize effectively in a fast-changing environment with minimal supervision
Strong analytical and troubleshooting skills.

Clinical Pharmacist

Key skills