Senior Clinical Pharmacist at CenCal Health

Santa Barbara, California, United States -

Full Time

Start Date

Immediate

Expiry Date

27 Mar, 26

Salary

261821.0

Posted On

27 Dec, 25

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Clinical Therapeutics, Managed Care Principles, Drug Utilization, Evidence-Based Medicine, Medication Use, Medi-Cal, Medicare, Utilization Management, Formulary Management, Medication Therapy Management, Data Analysis, Communication, Documentation, Workflow Development, Cross-Functional Activities

Industry

Hospitals and Health Care

Description

Job Details Job Location: Main Office - Santa Barbara, CA 93110 Position Type: Full Time Education Level: Doctorate Salary Range: $174,547.00 - $261,821.00 Salary/year Travel Percentage: None Job Category: Pharmacy Central Coast Annual Salary Range: $174,547 - $261,821 Annually While candidates from anywhere in California are welcome to apply, there is a strong preference for those who reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties). This role may offer opportunities for remote work; however, familiarity with and proximity to our local customers is valued. Job Summary The Senior Clinical Pharmacist provides advanced clinical and operational support for CenCal Health’s pharmacy programs. This role supports the pharmacy team in maintaining high-quality, compliant pharmacy services across all lines of business. Responsibilities include: Clinical Pharmacy Programs Drug Utilization Review (DUR) and Clinical Initiatives Utilization Management and Authorization Reviews Departmental and Cross Functional Support Duties and Responsibilities Clinical Pharmacy Programs Develops, implements, and maintains clinical pharmacy programs for all lines of business, including MTM, medication adherence, and disease state management. Responsibilities include: Contributing to the design and implementation of pharmacy programs that support organizational goals, medication-related quality measures (e.g., Star Ratings), and member experience. Evaluating and refining workflows to maintain program effectiveness and efficiency. Collaborating with Quality Improvement and Population Health teams to support medication-related quality initiatives. Supporting interventions to improve medication adherence, safety, and clinical outcomes. Monitoring delegated vendors and PBM activities through required reports and routine oversight. Assisting with PBM delegate and subdelegate oversight to ensure compliance with Medicare, Medi-Cal, accreditation standards, and internal policies. Overseeing and supporting MTM activities in partnership with the PBM, including CMRs, targeted reviews, chart review, and communication with members and prescribers. Drug Utilization Review (DUR) and Clinical Initiatives Maintains the DUR program and supports plan-wide clinical initiatives. Responsibilities include: Conducting prospective, concurrent, and retrospective DUR reviews in compliance with Medi-Cal, Medicare, and internal standards. Utilizing plan and PBM systems to identify utilization trends, safety concerns, potential misuse, and opportunities for intervention. Maintaining and updating the plan’s DUR dashboard. Developing provider-facing educational materials, drug alerts, and clinically focused communication. Supporting disease-management and care-coordination programs by providing pharmacy-related clinical insight. Utilization Management (UM) and Authorization Reviews Performs and supports the medication coverage determination process to ensure appropriate clinical decision-making and regulatory compliance. Conducting UM reviews using established policies, clinical criteria, Medicare/Medi-Cal regulations, and benefit coverage rules (including physician-administered drugs). Ensuring timeliness and accuracy of coverage determinations, redeterminations, and appeals in accordance with CMS requirements. Assisting in the development and maintenance of pharmacy criteria, UM workflows, and decision-support documents. Supporting the annual pharmacist inter-rater-reliability (IRR) process. Participating in the Pharmacy & Therapeutics (P&T) Committee and Subcommittee activities, including preparation of materials and reports. Reviewing drug utilization and claim trends to inform cost-effective benefit design recommendations. Responding to grievances, appeals, and inquiries related to the pharmacy benefit and collaborating with the Grievance & Appeals team as needed. Supporting oversight of PBM-delegated UM functions, including validation of PBM performance and documentation accuracy. Departmental & Cross-Functional Support Supports pharmacy initiatives aimed at improving operational performance, quality measures, and member outcomes. Assists with regulatory reporting, including CMS and DHCS submissions. Supports internal and external audits through data validation, documentation review, and follow-up. Collaborates with Operations, Compliance, Quality, Care Coordination, IT, and other departments to advance pharmacy-related initiatives. Participates in special projects and other duties as assigned to support the Pharmacy Director and departmental operations. Qualifications Knowledge/Skills/Abilities Required: Strong knowledge of clinical therapeutics, managed care principles, drug utilization, evidence-based medicine, and appropriate medication use. Working knowledge of Medi-Cal and Medicare Part B and Part D programs, including UM regulations formulary management, and MTM requirements. Ability to analyze pharmacy and claims data, identify trends, and interpret reporting metrics. Ability to communicate effectively, both orally and in writing, to members, providers, and internal stakeholders. Ability to maintain accurate documentation and manage multiple systems and software applications. Preferred: Knowledge of managed care and formulary benefit design. Education and Experience Doctor of Pharmacy (Pharm.D.) degree Active California pharmacist license in good standing. Minimum of four (4) years of managed care experience strongly preferred. Experience in staff supervision, workflow development, or cross-functional activities is desirable.

Responsibilities

The Senior Clinical Pharmacist provides advanced clinical and operational support for CenCal Health’s pharmacy programs, maintaining high-quality, compliant pharmacy services. Responsibilities include developing clinical pharmacy programs, conducting drug utilization reviews, and supporting medication coverage determinations.