SummaryPrimary duties include evaluating prescription claims data, developing and presenting clinically driven recommendations and initiatives, evaluating utilization management criteria and operational impact, supporting and maintaining configuration requirements, researching policy and regulatory drivers, and coordinating with operations, claims, network, reporting, medical management, population health, and other internal stakeholders. This role serves as a clinical leader, driving cross-functional collaboration to improve member outcomes, optimize pharmacy programs, and advance strategies across the organization.
Your role in our mission- Analyze clinical, utilization, prescribing, claims, and pricing data to identify opportunities that improve medication use, quality outcomes, cost effectiveness, medication adherence, preventive care, health equity, and population health performance.
- Develop, implement, manage, and evaluate utilization management programs, RetroDUR initiatives, clinical interventions, communications, clinical edits, coding, consultation tools, outreach efforts, and other pharmacy strategies aligned with organizational goals.
- Review prescribing patterns, prescription claims, and prior authorizations to identify gaps in care, high-risk populations, outlier practices, and opportunities to improve quality, safety, adherence, and member outcomes.
- Conduct provider consultations and evidence-based education, build collaborative provider relationships, and partner with Medical Directors and cross-functional stakeholders to support improved clinical and population health outcomes.
- Lead and collaborate across pharmacy, medical management, quality, care management, analytics, operations, claims, network management, technology, and other teams to implement programs, solve complex clinical and business challenges, and support evidence-based decision making.
- Present program methodologies, interventions, outcomes, and recommendations to governance committees, evaluate impact on quality and clinical objectives, and support regulatory and organizational performance measures.
- Serve as a pharmacy subject matter expert and strategic advisor, maintain current knowledge of medications, treatment guidelines, and industry best practices, and drive continuous quality improvement, operational excellence, innovation, and efficiency across pharmacy programs and operations.
- Perform other duties as assigned.
What we're looking for- Licensed Pharmacist.
- Minimum of five (5) years of experience in pharmacy benefit management or pharmacy managed care.
- Detailed knowledge of Medicaid programs at both state and federal levels.
- Ability to communicate succinctly and accurately in both written and verbal English across diverse audiences, including executive leadership, clients, providers, and large groups.
- Experience presenting complex clinical findings, recommendations, and program outcomes to senior leaders, clients, and governance committees.
- Ability to manage multiple projects simultaneously and effectively prioritize competing demands.
- Experience evaluating healthcare data, clinical outcomes, quality measures, and performance metrics.
- Demonstrated experience applying population health principles to improve medication use, quality outcomes, and healthcare delivery.
- Demonstrated leadership experience driving results through influence and collaboration across highly matrixed, cross-functional organizations.
- Proven success leading cross-functional teams and building partnerships across pharmacy, medical, quality, operations, analytics, provider engagement, care management, and technology functions.
- Experience with the end-to-end pharmacy claims lifecycle, clinical operations, medication pricing methodologies, NCPDP standards, financial management, managed care regulations, and healthcare quality initiatives.
- Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA) requirements.
- Strong PC skills with advanced proficiency in Microsoft Office, data analysis, project management, problem-solving, and virtual collaboration platforms such as Microsoft Teams, Zoom, and similar technologies.
What you should expect in this role- Ability to travel up to 25%, including occasional overnight travel.
- Remote position; candidates must reside within the United States.
The application period will remain open until August 5, 2026.
The pay range for this position is $135,000.00 - $165,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You'll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.
