JOB SUMMARY:The Clinical Pharmacist - Formulary & PBM Oversight serves as a clinical subject matter expert supporting formulary management, Pharmacy Benefit Manager (PBM) oversight, and pharmacy clinical programs across all lines of business. This position provides clinical oversight of delegated utilization management activities, supports Pharmacy & Therapeutics (P&T) Committee governance, monitors formulary strategy performance, and identifies opportunities to improve clinical quality, member experience, and pharmacy cost management.
The pharmacist also supports personalized member and provider interventions, formulary implementation and maintenance, and pharmacy financial and strategic initiatives.
KEY RESPONSIBILITIES:- Perform clinical audits of initial and appeal utilization management determinations across all lines of business to evaluate clinical appropriateness, consistency, application of coverage criteria, and compliance with regulatory and organizational requirements.
- Provide clinical oversight of delegated PBM utilization management and formulary activities, including monitoring performance, identifying trends or areas of concern, and recommending opportunities for improvement.
- Provide oversight and coordination of Pharmacy & Therapeutics (P&T) Committee activities, including review of PBM recommendations, formulary decisions, clinical criteria, and implementation activities.
- Monitor the clinical and financial impact of formulary strategies and utilization management initiatives, including member disruption, utilization trends, and overall program performance.
- Provide personalized member counseling and assistance related to formulary changes, medication access, therapeutic alternatives, and other medication-related needs.
- Develop and support prescriber notifications and targeted provider outreach related to formulary changes, therapeutic alternatives, and medication management opportunities.
- Develop and support provider education and academic detailing by identifying patient-specific opportunities for formulary optimization, therapeutic alternatives, medication access, and cost-effective, quality care; analyze data to track program impact, measure outcomes, and identify opportunities for improvement.
- Participate in pharmacy and finance collaboration, including pharmacy trend analysis, strategic budget development, forecasting, and evaluation of pharmacy cost-management opportunities.
- Support formulary implementation and maintenance and ensure accurate and timely publication of formulary information and updates on organizational websites and other member and provider resources.
- Collaborate with Pharmacy leadership, Medical Directors, Utilization Management, PBM partners, Finance, Provider Relations, Member Services, Compliance, and other stakeholders.
- Support clinical governance committees and other pharmacy initiatives as needed.
- Perform other job-related duties as required or assigned.
QUALIFICATIONS:
- Strong knowledge of managed care pharmacy, formulary management, utilization management, and PBM operations.
- Demonstrated understanding of Medicare Part D, Commercial, and Marketplace/Exchange pharmacy benefit operations.
- Knowledge of pharmacy coverage determinations, prior authorization, appeals, step therapy, quantity limits, and other utilization management processes and strategies.
- Ability to interpret and apply clinical literature, treatment guidelines, coverage criteria, and regulatory requirements.
- Understanding of delegated PBM clinical functions and health plan oversight responsibilities.
- Strong analytical, organizational, critical thinking, and decision-making skills.
- Ability to analyze pharmacy utilization, financial, and program performance data and translate findings into actionable recommendations.
- Excellent written, verbal, presentation, and collaboration skills.
- Proficiency with Microsoft Office applications and pharmacy information systems.
- Successful completion of Health Care Sanctions background check.
EDUCATION/EXPERIENCE:- Doctor of Pharmacy (PharmD) or Bachelor of Science in Pharmacy from an accredited School of Pharmacy.
- Active, unrestricted pharmacist license in the State of Oklahoma, or ability and willingness to obtain Oklahoma pharmacist licensure within 180 days of hire.
- Minimum of five years of clinical pharmacy experience in managed care pharmacy, health plan pharmacy, pharmacy benefit management, specialty pharmacy, or a related clinical practice setting.
- Experience with formulary management, utilization management, or PBM clinical programs preferred.
- Experience with Medicare Part D, Commercial, and/or Marketplace pharmacy benefits preferred.
- Experience with clinical auditing, P&T Committee activities, formulary strategy, data analysis, provider education, or member clinical programs preferred.
