The Clinical Review Pharmacist ensures members have safe and cost-effective access to necessary prescription drugs through prior authorizations and formulary management. They also monitor drug utilization, manage pharmacy costs, and collaborate with providers to improve quality metrics like STAR ratings and HEDIS.
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The Clinical Review Pharmacist works to ensure that ChenMed members have access to all medically necessary prescription drugs, and those drugs are used in a cost-effective, safe manner.
The incumbent completes prior authorizations for internal expert peer discussions (EPD) on high-cost medications to control appropriate medication use, following guidelines created by the organization.
Additionally, they are involved in formulary management (such as reviewing prior authorization requirements, reviewing drug/provider utilization patterns and pharmacy costs management), clinical pharmacy services (such as therapeutic drug monitoring, drug regimen review, patient education, and medical staff interaction), and oversight (establishing and measuring performance metrics regarding patient outcomes, medications safety and medication use policies).
ESSENTIAL JOB DUTIES/RESPONSIBILITIES: Reviews coverage determinations and appeals in a timely, compliant, and accurate manner.
Ensures compliance with the coverage determination and appeals process.
Acts as a liaison between ChenMed and its patients with respect to the clinical guidelines we practice.
Serves as the formulary expert for the therapeutic class they are reviewing.
Contributes to projects aimed at improving STAR ratings, HEDIS, CAHPS, and other quality metrics.
Assists with clinical questions and phone calls from prescribers, pharmacies and/or ChenMed members.
Develops, implements and maintains pharmacy cost control and quality initiatives under the direction of leadership and guidelines.
Monitors drug utilization and assists Pharmacy leadership team in understanding quality and cost control issues.
Acts as a liaison between ChenMed and its members with respect to the pharmacy benefits.
Works with providers to ensure accurate coverage determination decisions.
Performs outreach to patients and providers as part of quality and/or cost control initiatives.
Performs other duties as assigned and modified at manager’s discretion.
Excellent analytical and deductive reasoning skills; detail oriented Good judgement and problem-solving skills Knowledge of and experience with state and federal insurance programs Familiarity with appropriate local, state, and federal pharmacy laws and regulations Ability to work effectively independently and as part of a team Ability to communicate effectively with staff, management, executives and patients/members Strong organization and time management skills and multi-tasking abilities Written and verbal fluency in English; bilingual preferred Proficient in the use of Microsoft Office products such as Outlook, Excel, Word and PowerPoint Willingness to travel locally up to 50% of the time; flexible to work evening, weekends and/or holidays as needed This job requires use and exercise of independent judgment EDUCATION AND EXPERIENCE CRITERIA: Doctorate of Pharmacy (PharmD) required Must have a License that is in good standing Minimum one (1) year of pharmacy experience Minimum one (1) year of utilization review experience preferred Pharmacy residency training is preferred, but not required Experience in a managed care setting (HMO, MSO, PBM) is a plus Medicare Part D or Medicaid experience, along with managed care experience PAY RANGE: $118,062 - $168,658 Salary The posted pay range represents the base hourly rate or base annual full-time salary for this position. Final compensation will depend on a variety of factors including but not limited to experience, education, geographic location, and other relevant factors. This position may also be eligible for a bonuses or commissions. EMPLOYEE BENEFITS https://chenmed.makeityoursource.com/helpful-documents We’re ChenMed and we’re transforming healthcare for seniors and changing America’s healthcare for the better. Family-owned and physician-led, our unique approach allows us to improve the health and well-being of the populations we serve. We’re growing rapidly as we seek to rescue more and more seniors from inadequate health care. ChenMed is changing lives for the people we serve and the people we hire. With great compensation, comprehensive benefits, career development and advancement opportunities and so much more, our employees enjoy great work-life balance and opportunities to grow. Join our team who make a difference in people’s lives every single day. Current employees, if you want to apply to our internal career site, please click HERE Current Contingent Worker please see job aid HERE to apply #LI-Hybrid
A Doctorate of Pharmacy (PharmD) and a license in good standing are required, along with at least one year of pharmacy experience. Experience in utilization review and managed care settings (HMO, MSO, PBM) is preferred.
Market context
In Florida, ambulatory care pharmacy roles are often competitive because employers typically look for an active Florida pharmacy license plus specialized residency training or several years of clinical ambulatory care experience. Spanish proficiency can be a meaningful advantage in patient-facing settings, especially where bilingual communication supports care access. Review the AI-summarized requirements and benefits here to quickly compare fit, since they are distilled from the original posting and can save research time before you apply.
