Pharmacist - Clinical Prior Authorization

The Job

This position will play an important role in managing Medicare Part B Formulary; evaluation and review of new drugs with the Pharmacy & Therapeutics Subcommittee / Committee. This position is accountable for ensuring regulatory compliance with respect to the Medicare Part B formulary submissions to CMS, pharmacy benefits, formulary and website content for all business lines, pharmacy network and CMS’s Part B regulatory audits. The Clinical Pharmacist stays abreast of pharmacy, and payer industry changes, best practices, and CMS’s rules and regulations. This position will have supervisory duties.

You Will

Review part b medication and other prior authorization requests for clinical appropriateness, cost-effectiveness, and evidence-based guidelines. Ensure all authorization requests align with the health plan's formulary, clinical policies, and industry-standard treatment protocols. Collaborate with providers to review alternative medications or therapies that may be more clinically appropriate or cost-effective.

Site of Service Optimization : Evaluate requests to ensure medications are administered in the most clinically appropriate and cost-effective setting (, in-office, outpatient, home infusion, etc.). Educate providers on site of service optimization opportunities to help reduce overall healthcare costs while maintaining high-quality care.

Clinical Expertise & Evidence-Based Guidance : Provide cost-effective evidence-based recommendations on specialty therapies, utilizing national guidelines (, NCCN, ASCO) to optimize patient outcomes and medication use. Assist in the development and review of clinical policies related to oncology specialty medications, ensuring they reflect the latest research and best practices.

Collaboration & Communication : Work with physicians, oncologists, and other healthcare providers to facilitate the approval of appropriate treatments. Communicate directly with providers to discuss medication alternatives, treatment regimens, and any potential barriers to authorization. Educate and inform both internal and external stakeholders on new part b therapies, formulary changes, and best practices for cost-effective care.

Utilization Management & Cost Control : Ensure that all oncology medication requests are aligned with the health plan's cost control and formulary management strategies. Assist in the identification of opportunities for cost savings while maintaining high-quality, evidence-based care. Participate in cost-effectiveness reviews and comparative effectiveness analyses of oncology treatments.

Documentation & Compliance : Accurately document all authorization decisions and clinical justification within the health plan’s system. Ensure all prior authorization requests comply with federal, state, and plan-specific regulations. Participate in audits and quality assurance activities related to part b medications.

Education & Training : Provide education and training to internal teams (, customer service, case management, pharmacy staff) on oncology medications, policies, and procedures. Keep abreast of developments in drug therapies, treatment guidelines, and industry trends.

Supervises / Manages Others ( hires, performance reviews, corrective action, etc.)

All other duties as assigned.

Your Qualifications

Graduate or Advanced Degree required

Pharmacists License required - California Pharmacy Licensure, required within 6 months of hire

At least 2-3 years of pharmacy practice, with a strong preference for prior authorization or oncology experience in a health plan or clinical setting.

Familiarity with oncology therapies, treatment regimens, and site of service optimization strategies.

Experience with clinical guidelines such as NCCN, ASCO, or similar standards.

Strong analytical and problem-solving skills to evaluate clinical data and determine medication coverage and authorization.

At least 2-3 years of experience in healthcare, medical management, change management, and / or leadership.

Leadership - Basic skills to develops others

Problem Solving - Basic problem-solving skills

Communication - Good communication and interpersonal skills

Strong communication and interpersonal skills to effectively collaborate with healthcare providers and internal stakeholders.

Excellent organizational skills with attention to detail and the ability to manage multiple tasks and priorities.

Proficiency with medical literature, clinical guidelines, and evidence-based medicine in oncology.

Ability to apply critical thinking in medication therapy management and optimization.

Familiarity with electronic health record (EHR) systems and pharmacy management software.

What's in it for you?

• Base salary range : $125, to $200, per year
• Internal title - Pharmacist
• Work Mode - Mostly Remote
• An annual employee bonus program
• Robust Wellness Program
• Generous paid-time-off (PTO)
• Eleven paid holidays per year, plus 1 floating holiday, plus 1 birthday holiday
• Excellent 401(k) Retirement Saving Plan with employer match and contribution
• Robust employee recognition program
• Tuition reimbursement
• An opportunity to become part of a team that makes a difference to our members and our community every day!

Salary : $125 - $200