CLINICAL PHARMACIST JOB DESCRIPTION

A Clinical Pharmacist in managed care is not simply a dispensing professional. The role carries ownership of drug utilization review programs, formulary governance, and CMS regulatory compliance - each a distinct function with real stakes for health plan members. Formularies drift, prior authorization backlogs accumulate, and NCQA audit findings go unresolved when this seat operates below standard. The Clinical Pharmacist is the technical and clinical anchor for a pharmacy department serving Medicare Advantage or Prescription Drug Plan populations.

As the Clinical Pharmacist, you serve as the clinical authority for formulary management, drug utilization review, and regulatory compliance across a managed care pharmacy program, ensuring member medication access meets CMS and NCQA standards. Working within a pharmacy or clinical operations department, you collaborate with Medical Directors, PBM account teams, and care management staff to translate Part D guidance into compliant, member-centered benefit design.

Career Impact: Deep fluency in Medicare Part D regulatory requirements and NCQA audit processes positions a pharmacist among the most sought-after specialists in health plan operations.

Business Impact: The formulary decisions and utilization review programs this role owns directly determine whether a health plan's pharmacy benefit remains compliant, cost-effective, and accessible to high-risk members.

Growth Opportunity: Experience managing CMS-regulated clinical programs and drug rebate structures opens pathways to Pharmacy Director, Clinical Program Director, or PBM consulting roles.

• Conduct prospective and retrospective drug utilization review across the managed care membership to identify suboptimal or duplicative therapy.
• Manage formulary development and maintenance, including prior authorization criteria, step therapy protocols, and non-formulary exception programs.
• Monitor compliance with CMS Medicare Part D guidelines and NCQA accreditation standards, escalating issues to the Office of Compliance as required.
• Collaborate with Medical Directors and care management teams on treatment guidelines and drug coverage policies that meet clinical and regulatory expectations.
• Perform Comprehensive Medication Reviews for high-risk members, addressing drug-related problems, interactions, and adherence barriers in partnership with PCPs.
• Analyze drug utilization trends and prepare ad hoc and routine reporting to support pharmacy leadership and committee functions.
• Support the Pharmacy and Therapeutics Committee by synthesizing clinical evidence and utilization data into actionable formulary recommendations.
• Educate internal and external stakeholders on Part D benefit design, formulary features, and medication management program updates

• Doctor of Pharmacy degree from an ACPE-accredited school of pharmacy, or Bachelor of Science in Pharmacy with equivalent advanced clinical experience.
• 3 or more years of clinical pharmacy experience within a managed care, Medicare Advantage, or Prescription Drug Plan environment.
• Current, unrestricted state pharmacy license in good standing, with eligibility to obtain licensure in required states.
• Knowledge of Medicare Part D benefit structure, including formulary tiering, coverage determination, and CMS operational requirements.
• Understanding of drug utilization review methodology, formulary design principles, and pharmacy benefit management operations.
• Familiarity with NCQA, DMHC, or DHCS accreditation and audit standards as applied to pharmacy programs.
• Demonstrated ability to analyze regulatory guidance and translate requirements into compliant internal procedures.
• Strong written and verbal communication skills, with experience preparing reports, desktop procedures, and committee materials.

• ASHP-accredited PGY1 residency in pharmacy practice or equivalent structured clinical training.
• Board certification in Pharmacotherapy or a relevant specialty, or active progress toward certification.
• Experience with CMS audit response, corrective action planning, or NCQA survey preparation.
• Prior exposure to drug rebate program administration or pharmacoeconomic analysis in a health plan setting.

• Drug utilization review completion rate, measured as percentage of targeted member cases reviewed on schedule.
• Prior authorization turnaround time, reflecting responsiveness against CMS-required determination windows.
• Formulary exception denial rate, indicating accuracy of clinical criteria application relative to peer benchmarks.
• NCQA or CMS audit finding count per review cycle, measuring regulatory compliance posture of the pharmacy program.
• Medication adherence rate for managed chronic condition populations, reflecting effectiveness of CMR and MTM interventions.
• Typical tools: pharmacy benefit management platforms (commonly MedImpact or similar); office productivity suites (commonly Microsoft Excel, Word, Outlook).

• Base Salary Range: $115,000 to $145,000 annually, varying by market and plan size
• Bonus: Annual performance bonus of 5% to 12% of base salary
• Equity: Generally not offered in health plan settings; some larger systems offer stock purchase plans
• Health Benefits: Medical, dental, and vision coverage; typically employer-subsidized
• PTO: 15 to 22 days annually, plus observed federal holidays
• Common Perks: Tuition reimbursement, continuing pharmacy education stipend, licensure fee coverage

Figures are estimates based on general US market benchmarks and may be outdated. Adjust based on location, company size, and seniority level.

Successful completion of a background check, which may include criminal history and drug screening consistent with healthcare regulatory requirements, is a condition of employment. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, disability, veteran status, or any other characteristic protected under applicable federal, state, or local law. Reasonable accommodations are available to applicants and employees with disabilities upon request. Candidates must be authorized to work in the United States.

The Clinical Pharmacist (Audit & Oversight) leads routine oversight, monitoring, and auditing of PBM and internal pharmacy functions, partnering with the Pharmacy Management department to develop compliance reporting and drive Part D issue resolution. Reporting to pharmacy leadership, this role owns Medicare Part D regulatory compliance across first tiered and downstream entities, enabling the organization to meet CMS, DHCS, DMHC, and NCQA standards.

Key Responsibilities

• Participate in a mission driven culture of high-quality performance, with a member focus on customer service, consistency, dignity, and accountability.
• Assist the team in carrying out department responsibilities and collaborate with others to support short and long-term goals and priorities for the department.
• Partner with the Pharmacy Management department on establishing and monitoring operational Part D metrics, updating dashboards, logs and other reports.
• Drive Part D issue resolution with internal business and first tiered, downstream Part D entities.
• Ensure that first tiered, downstream Part D entities are compliant with Part D Centers for Medicare and Medicaid Services regulations.
• Alert the Office of Compliance of any issues requiring immediate business owner notification.
• Monitor and measure the impact of new Part D guidance and requirements.
• Work with the Pharmacy Management department to develop oversight reporting to ensure compliance.
• Perform routine and ad hoc reporting, including designing reports and desktop procedures for department activities.
• Develop materials, coordinate and analyze data, and prepare information for reports.
• Provide information from monitoring of procedures to facilitate improvement to Medicare Part D compliance processes and support workgroups and committees, as needed.
• Manage multiple, concurrent projects for completion within given deadlines.
• Communicate clearly and concisely, both verbally and in writing.
• Analyze data and formulate conclusions and recommendations.

Required Qualifications

• Pharm.D. required.
• Current, valid, unrestricted California State Pharmacy License required.
• ASHP-accredited residency in Pharmacy Practice or equivalent background and experience required.
• 3 years of experience in a Medicare Advantage and Prescription Drug Plan with experience analyzing and interpreting regulatory requirements required.
• 5 years of experience in clinical pharmacy practice including performing drug use evaluations preferred.
• Medicare Part D Plan operations experience preferred.
• Work experience in a Pharmacy benefit manager contracted to provide Medicare Part D services preferred.
• CMS, DMHC, DHCS and/or NCQA audit experience preferred.
• Knowledge of current clinical pharmacotherapeutics, pharmacology and disease state management.
• Knowledge of pharmacy benefit design, managed care pharmacy operations, formularies and pharmacy nomenclature.
• Knowledge of Medicaid and/or Medicare programs.
• Knowledge of principles of pharmacoeconomics.
• Knowledge of managed health care principles and managed health care organizations.
• Knowledge of regulatory and accreditation standards and guidelines for DHCS, DMHC, NCQA and CMS.
• Proficient in Microsoft Office Excel, Outlook, PowerPoint, and Word.

Embedded within the POD Care team, the Clinical Pharmacist conducts Comprehensive Medication Reviews and Targeted Medication Reviews for high-risk members, collaborating with PCPs and the POD Care Coordinator to resolve drug-related problems and improve adherence. Working closely with patients and providers, this role delivers medication therapy management that reduces barriers to adherence and supports positive disease state outcomes.

Core Functions

• Conduct Comprehensive Medication Reviews for members identified as High Risk, members referred from PCPs and the POD Care Manager.
• Conduct Medication Reconciliation Post-Discharge with members discharged from inpatient facilities.
• Collaborate with POD Care Coordinator to facilitate post-discharge PCP and Specialist appointments and 90-day visits on behalf of member.
• Focus during Medication Reviews on potential drug related problems, drug to drug interactions, cost-savings opportunities, duplicative or unnecessary drug use.
• Consult and recommend to the PCP alternative pharmacotherapy based on results of CMRs.
• Meet with PCP to discuss the recommended adjustment plan and meet with PCP and member as needed.
• Conduct Quarterly Targeted Medication Reviews.
• Monitor POD member medication compliance and consult with members to ensure medication compliance.
• Educate members on importance of medication compliance and benefits of home delivery.
• Identify and address patient specific barriers to medication adherence and disease state management.
• Collaborate with patient's PCP to overcome barriers and improve adherence and disease state management.
• Provide education to providers when needed related to member medication management issues.

Qualifications & Experience

• Doctor of Pharmacy degree from an accredited School of Pharmacy required.
• Current licensure in the state of Georgia required.
• 3 or more years of experience in a clinical pharmacy setting with direct patient care experience required.
• 2 or more years of experience communicating with patients, providers, and other healthcare professionals required.
• Experience with Medication Therapy Management and Comprehensive Medication Reviews required.
• In depth knowledge of pharmacotherapy and pharmacy practice required.
• Proficient in Microsoft Excel and able to quickly learn clinical applications.

Reporting to pharmacy leadership, the Clinical Pharmacist provides comprehensive medication management for inpatient and outpatient hospital populations through review of physician orders, dispensing, and monitoring of drug therapies to achieve positive patient outcomes. Partnering with pharmacy technicians, students, and clinical staff, this role shapes safe and accurate medication delivery in full alignment with Joint Commission, Department of Health, and institutional standards.

Primary Duties

• Provide comprehensive, quality medication management for patients through application of pharmacy practice standards.
• Review physician orders and dispense medications and pharmaceutical preparations to inpatient and outpatient areas of the hospital.
• Maintain accurate patient profiles and monitor and help manage drug therapies to achieve positive patient outcomes.
• Oversee pharmacy technicians and students and ensure accuracy of their work prior to dispensing.
• Adhere to Pharmacy Policies, Procedures, organizational goals and objectives.
• Perform duties in accordance with entity values, policies, and procedures.

Skills & Qualifications

• Bachelor of Science degree in Pharmacy or Doctor of Pharmacy degree from an accredited College of Pharmacy required.
• Valid and active PA license in good standing required.
• Understanding of the Joint Commission and Department of Health process required.
• Ability to perform dosage calculations required.
• Strong communication skills with all levels of staff and personnel required.

Sitting at the intersection of clinical pharmacy practice and population health management, the Clinical Pharmacist evaluates and designs patient-specific pharmacotherapeutic regimens, manages chronic conditions including diabetes, hypertension, and COPD, and documents clinical outcomes to support quality measures such as HEDIS and Star ratings. Operating across interdisciplinary care teams, this role builds medication safety programs and contributes to formulary development and best practice protocols for specialized patient populations.

Duties

• Evaluate, monitor, recommend and design patient-specific pharmacotherapeutic regimens.
• Participate in pharmacy activities to assure safe, effective, appropriate, and economical use of medications.
• Manage chronic conditions such as diabetes, hypertension, and COPD to help patients reach clinical goals.
• Help prevent avoidable medication-related hospitalizations.
• Serve as a resource to practice physicians, nurses, and other team members on general drug information.
• Regularly monitor patient data and metrics to evaluate program effectiveness and clinical outcomes.
• Understand medication-based quality measures as used in Pay for Performance, Star, and HEDIS measures.
• Document clinical activities, outcomes, and quality intervention results.
• Provide education on prescribed medications and compounds according to professional standards and practices.
• Participate in committees and meetings to facilitate improvement of patient care and development of goals and programs for specialized patient populations.
• Participate in problem-solving about best practice development for high cost or sub-optimal medication therapies.

Education & Experience

• PharmD degree required.
• Board of Pharmaceutical Specialty Certification or ASHP Residency completion with two years of clinical experience required.
• Doctor of Pharmacy degree with three years of clinical experience plus a certificate program.
• B.S. degree with five years of clinical experience and two certificate programs.
• BCPS certification preferred.
• Current active license to practice pharmacy in North Carolina required.
• National Provider Identifier required.
• 3 years of clinical experience required.
• Extensive knowledge of pharmacy and related subdisciplines including therapeutics, pharmacology, formulary development, drug use review, quality assurance, and regulatory standards.
• Experience in the medication reconciliation process.
• Knowledge of principles of clinical integration and population health management.
• Proficient in Electronic Health Records Systems.
• Working knowledge of enterprise data warehouses and patient registries.
• Proficient in Microsoft Teams, Word, Excel, and PowerPoint.
• Ability to work independently and meet expected deadlines.
• Ability to work collaboratively as a member of an interdisciplinary team and establish effective working relationships with healthcare professionals, patients, and families.

A key member of the Medicare clinical operations team, the Medicare Clinical Pharmacist authorizes drug formulary changes, interprets CMS guidance, and oversees vendor clinical operations to ensure full compliance with Medicare Part D regulations. Collaborating across Medical Directors, Care Management, and PBM Account Management, this role delivers the regulatory and clinical program infrastructure that supports compliant and effective Medicare Part D benefit administration.

Functions

• Provide direction to PBM Account Management team for design of Medicare operational procedures.
• Provide pharmaceutical support for design and implementation of Medicare clinical programs including prior authorizations, step therapy and quantity limits.
• Authorize drug formulary changes for the Medicare Part D program and provide feedback for potential revisions and maintenance of the drug formulary.
• Manage and provide oversight of vendor related clinical operations.
• Implement business operations as required by CMS.
• Interpret CMS guidance and apply knowledge to conducting business processes.
• Manage assigned projects within the established budget and timelines.
• Provide subject matter expertise for development of clinical programs.
• Monitor compliance with CMS guidelines and regulations.
• Coordinate and integrate with Medical Directors and other department members regarding medication therapies, drug coverage guidelines and related issues.
• Coordinate and integrate with the Care Management team, Senior Educators and Senior Markets staff regarding responses to member and agent inquiries.
• Coordinate and integrate drug utilization review programs for the Medicare Part D product.
• Document and maintain supporting data for clinical programs.
• Inform and educate internal and external stakeholders on the features and services of the Medicare Part D product.
• Analyze drug trends and review with providers as needed.

Minimum Qualifications

• Bachelor of Science or PharmD in Pharmacy required.
• Current Florida Pharmacy License required.
• Clinical knowledge of prescription drug products, dosage forms and drug classification types.
• Knowledge of Medicare Part D benefit structure including tiering, formulary, and non-formulary drugs.
• Experience with medical terminology and medical coding including ICD9 and HCPCS.
• Proficient in Microsoft Word, Excel, and Outlook.
• Ability to successfully meet deadlines and achieve results in a dynamic, ever-changing environment.
• Experience in patient consultative skills and ability to deal with conflict and negative feedback in a customer centric manner.

Safe and compliant investigational drug management depends on the Clinical Pharmacist, who prepares and dispenses investigational and commercial drug products, maintains clinical trial pharmacy records, and ensures legal and regulatory compliance within the investigational pharmacy. Based within a research setting, this role supports multi-disciplinary research teams and IRB auditors by managing drug inventory and creating medication entries for each new clinical trial.

Accountabilities

• Prepare and dispense investigational and commercial drug products subsequent to a physician order.
• Ensure legal and regulatory compliance within the investigational pharmacy.
• Receive, store, maintain, and dispose of drug inventory for clinical trials in accordance with regulatory policies and procedures.
• Maintain all clinical trial related pharmacy records within the investigational pharmacy.
• Assist in creating investigational medication entries in the pharmacy system dictionary for each new clinical trial.

Experience & Qualifications

• Excellent knowledge of clinical practices, phases of clinical research, and ethical research methods required.
• Competency in preparing sterile compounds and/or chemotherapy required.
• Proficient in Windows-style applications including Microsoft Word, PowerPoint, and Excel.
• Ability to communicate with physicians, research staff, IRB, and auditors effectively and professionally.
• Ability to interact proactively with multi-disciplinary research team members.
• Strong time-management skills to efficiently manage multiple job functions daily.

As the Clinical Pharmacist Specialist, this role oversees drug usage and optimizes medication therapy across all areas of medication management, with a primary focus on antimicrobial stewardship through interdisciplinary rounds, protocol development, and Medication Use Evaluations. The pharmacy and clinical team relies on this work to advance evidence-based prescribing, support drug shortage strategies, and develop pharmacy students through structured preceptorship.

Role Responsibilities

• Evaluate the appropriateness and effectiveness of medications, with a focus on antimicrobials, through interdisciplinary rounds, antimicrobial stewardship leadership and surveillance.
• Collaborate with physicians and other health care providers in selecting medication therapy that best meets patient needs and contributes to overall therapy goals.
• Apply specialized knowledge of the scientific and clinical use of medications including medication action, dosing, adverse effects, and drug interactions.
• Take an active role in the development and implementation of protocols, antimicrobial stewardship initiatives and appropriate drug utilization.
• Provide education to the healthcare team including pharmacists, nurses, physicians and students through in-services, presentations, lectures, clinical pearl memos and competencies.
• Perform Medication Use Evaluations and formulary reviews.
• Educate the healthcare team on new formulary medications, updated policies and procedures, medication safety initiatives and drug shortages.
• Develop rapport with medical and nursing staff and other multidisciplinary departments by actively seeking opportunities to improve patient care and medication management.
• Attend assigned meetings, understand the goals and strategy of the meeting, and actively participate in achieving those goals.
• Respond to immediate medication needs and questions from pharmacy, nursing, physicians and patients in a timely and accurate manner.
• Develop alternative strategies for drug shortages.
• Provide practical experience and training to pharmacy students including patient care rounds, topic discussions, seminar presentations, patient case presentations and journal clubs.

Background & Experience

• Active NJ Pharmacist license required.
• PGY1 Pharmacy Residency preferred.
• PGY2 Pharmacy Residency or strong aptitude in Infectious Diseases and Antimicrobial Stewardship preferred.
• Prior Clinical Specialist experience preferred.
• Excellent verbal and written communication skills required.
• Proficient in Microsoft Word, Excel, and PowerPoint.

Clinical Pharmacist delivers prospective and retrospective drug utilization review, collaborates with medical personnel on treatment guidelines, and manages formulary programs to improve medication regimen quality across a managed care membership. Success in the position means supporting the Pharmacy and Therapeutics Committee, maintaining rebate and non-formulary exception programs in compliance with state and federal guidelines, and enabling accurate provider dispensing and billing.

Job Functions

• Improve quality of service to members by providing prior-authorization of formulary drugs and developing programs to provide optimal pharmacy care to patients.
• Participate in dispute resolution of drug utilization review and measure and document improvements in patient care.
• Collaborate with other medical personnel in developing treatment guidelines and demonstrate the impact of these guidelines.
• Participate in formulary development and management as needed.
• Monitor prescribing habits of participating physicians and make recommendations to improve medication regimens as appropriate.
• Maintain the non-formulary exception program and/or the rebate program consistent with contract, state and/or federal guidelines.
• Audit providers to ensure accurate dispensing and billing of products as needed.
• Collaborate with the pharmaceutical community to ensure timely payment is maintained.
• Support drug rebate regulations and mandates by maintaining pharmaceutical reimbursement methodology for multisource products.
• Validate the clinical availability of multisource products for provider utilization.
• Support the Pharmacy and Therapeutics Committee function.
• Develop and maintain a newsletter for provider staff promoting rational prescribing habits as needed.

Professional Experience

• Bachelor's degree from an accredited school of pharmacy or Pharm.D. from an accredited school of pharmacy required.
• Board certification and residency preferred.
• Current unrestricted state license required.
• At least 6 months of previous clinical pharmacy experience required.
• Managed care experience preferred.
• Knowledge of clinical program components, formulary designs, and prescription benefit trends preferred.
• Understanding of medical and pharmacy terminology required.

The Clinical Pharmacist (Family Practice/OUD) develops OUD and mental health treatment guidelines, provides clinical pharmacy services via telehealth to rural sites, and serves as a preceptor for PharmD candidates within the Ambulatory Care Pharmacy Services department. Reporting to the Department of Pharmacy Practice, this role produces evidence-based therapeutic plans and collaborative treatment protocols that advance medication management outcomes for patients with opioid use disorder and co-occurring mental health conditions.

What You'll Do

• Provide clinical pharmacy services including education on medications used in Opioid Use Disorder and mental health across local sites and via telehealth technology at rural sites.
• Develop OUD and mental health treatment guidelines and support special projects.
• Interact with and serve as preceptor model for PharmD candidates.
• Respond to provider consultations.
• Establish patient-pharmacist relationships and support nurse, physician, and pharmacy staff development.
• Create, recommend and implement comprehensive individualized evidence-based therapeutic plans.
• Coordinate and conduct quality initiative and research projects.
• Develop collaborative treatment protocols.

Knowledge Skills & Abilities

• Graduate of an ACPE accredited PharmD program required.
• ASHP accredited PGY1 and PGY2 Pharmacy residency completion required, or 2 to 3 years of equivalent experience in Ambulatory Care.
• Board Certification recommended.
• Illinois licensure as a professional pharmacist required by start date.
• Previous management experience highly desired.
• Knowledge and skills qualifying for a non-tenured faculty position with the Department of Pharmacy Practice required.
• Bilingual in English and Spanish preferred.

Embedded within a full-service hospital pharmacy, the Clinical Pharmacist interprets and fills physician orders, compounds IV admixtures, and provides clinical services across all patient populations from infant through geriatric. Working closely with the pharmacy director and lead pharmacist, this role advances safe and compliant medication delivery in accordance with hospital policies, state and federal law, and age-specific care standards.

Day-to-Day Responsibilities

• Interpret, fill and check physician orders.
• Compound and check IV admixtures.
• Adhere to hospital policies, standards of practice of the profession and State and Federal laws.
• Perform clinical activities as determined by pharmacy director or lead pharmacist.
• Provide services for all populations of patients including infant, child, adolescent, adult, and geriatric.

Position Requirements

• Bachelor of Science Degree in Pharmacy or Pharm.D. Degree from an accredited College of Pharmacy required.
• Current licensure to practice Pharmacy in the State of Texas in good standing required.
• Minimum of 1 year of current experience in hospital pharmacy preferred.
• Experience appropriate for meeting age-specific needs of pediatric, adolescent, adult and geriatric patients required.
• Experience in IV admixture and unit dose drug distribution system required.
• Experience with computerized pharmacy systems required.

Benefit

• 401k, life, disability, tuition reimbursement.
• PTO medical, dental, flex spending.
• Employee discount program, employee stock purchase program and student loan repayment.