Fallon Health·Worcester, Massachusetts
The clinical pharmacist will review and provide clinical decisions for provider and member appeals and grievances regarding medications. They will also analyze pharmacy data to assist with utilization management and support formulary development across all lines of business.
Primary Job Responsibility Responsible for reviewing and providing clinical decisions/recommendations for provider/member submitted appeals and grievances for medically administered medications as well as pharmacy related medications and items for all lines of business. Collaborate with the Appeals & Grievance Department, Medical Directors, and Prior Authorizations vendors. Maintain turnaround times for all appeal and grievance reviews. Review appeal/grievance requests per plan-specific criteria, MassHealth-developed criteria, National Coverage Determinations, and Local Coverage Determinations, Evidence of Coverage, Member Handbooks. Follow regulatory rules and processes for Massachusetts, CMS, Medicaid, state Connector programs. Consult with internal and external stakeholders as needed. Consult with providers. Participate in managing clinical issues resolution; work with medical providers and vendors to coordinate and resolve member issues. Provide recommendations, as appropriate, to update current prior authorization criteria due to appeals and grievance data. Assist with formulary and criteria development for all lines of business. Participate in general drug information support for internal and external clients. Provide clinical assistance to pharmacy staff for daily operations.
Qualifications requirements Education RPH or Pharm D License Current license to practice as pharmacist in Massachusetts without restriction Experience 3 years, preferably with at least 1 year in a managed care environment; 1-2 years professional experience practicing as a clinical pharmacist. Recent experience related to member and/or provider appeals and drug coverage determinations is a plus. Able to evaluate clinical pharmacy data, coverage criteria and drug monographs. Able to understand and use computer databases, EMRs, Excel, Word, PowerPoint and others. Able to write and orally communicate clinical decisions to physicians and other healthcare personnel. Excellent communication skills, coordination, and planning skills along with an ability to interact with a variety of audiences to build collaboration and consensus. Pay Range Disclosure:In accordance with the Massachusetts Wage Transparency Act, the pay for this position is $ 135,000-$145,000 annually which reflects what we reasonably and in good faith expect to pay at the time of posting. Final compensation will depend on the candidate’s experience, skills, and fit with the role’s responsibilities. Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. #P01
Candidates must hold a current RPH or PharmD license in Massachusetts without restriction. A minimum of 3 years of experience, including at least 1 year in a managed care environment, is required.
Market context
Pharmacy technician roles in Massachusetts are typically driven by ongoing staffing needs in retail, hospital, and outpatient settings, where accuracy and customer service matter every day. Competition can be strong because employers often look for state registration, PTCB or NHA certification, and solid communication, math, and computer skills. Review the original posting carefully and confirm your credentials match the requirements; this platform’s AI-summarized requirements and benefits help you compare roles faster without reading every full description.