Welcome to Montage Health's application process!

Job Description:

Position Summary

The Clinical Pharmacist Utilization Management serves a critical role across utilization management, quality improvement, and regulatory compliance for Medicare Advantage and commercial pharmacy benefits. This position is responsible for making accurate, evidence-based coverage determinations and appeal decisions, supporting pharmacy quality initiatives tied to CMS Star Ratings, and ensuring compliance with CMS regulations.

The pharmacist functions in a highly cross-functional capacity, partnering with operations, quality, compliance, vendors, providers, and customer service teams to improve medication access, safety, adherence, and member experience across all lines of business.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Perform Part B and Part D coverage determinations and appeals in accordance with CMS regulations, plan benefits, and evidence-based clinical guidelines.

• Conduct clinical drug utilization reviews and appropriately apply formularies and preferred drug lists.

• Manage pharmacy quality programs impacting CMS Star Ratings, medication adherence, and Medication Therapy Management (MTM).

• Provide medication therapy management (MTM) services, including outreach to members, providers, and pharmacies.

• Support CMS audits, regulatory reporting, grievances, and PBM formulary compliance activities.

• Manage pharmacy quality vendors, including MTM and medication adherence programs.

• Assist in the preparation of materials or activities related to the Pharmacy and Therapeutics (P&T) and Utilization Management subcommittee.

• Conduct telephonic member outreach to answer member questions, resolve member issues and close care gaps.

• Complete interventions to improve biosimilar conversions across all lines of business.

QUALIFICATIONS:

• Pharm.D. or RPh from an accredited School of Pharmacy.

• Active, unrestricted pharmacist license in California.

• Medicare Advantage Part B and Part D utilization management experience preferred.

• Strong analytical, organizational, and written/verbal communication skills.

Salary Range: $129,000 - $169,000 per year. Actual compensation varies by location, experience, education, and skill level.

Equal Opportunity Employer

Assigned Work Hours:

Full-time (Exempt)

Position Type:
Regular