Clinical Programs Pharmacist

The Clinical Pharmacist will receive direction from the Sr. Director of Pharmacy Solutions to support the development, implementation, and oversight of clinical programs. This position is responsible for reviewing and adjudicating prior authorization requests, developing and maintaining evidence-based clinical criteria, and serving as a clinical resource for pharmacy technicians and cross-functional teams. The role ensures safe, appropriate, and cost-effective medication use while aligning with client benefit design and regulatory requirements. They will assist in the communication between members, brokers, HR, and their direct report needed to ensure retention and operational excellence.

Responsibilities

Prior Authorization & Utilization Management

• Review and provide oversight of complex or escalated prior authorization requests
• Document clinical determinations clearly and accurately
• Participate in peer-to-peer discussions when necessary
• Develop and maintain evidence-based prior authorization criteria, step therapy protocols, and quantity limits
• Ensure alignment between clinical guidelines, plan documents, and operational execution
• Identify opportunities to enhance clinical rigor while maintaining operational efficiency

Formulary & Benefit Strategy Support

• Assist in formulary evaluation and design recommendations
• Evaluate clinical and financial impact of new brand and generic launches
• Monitor therapeutic class changes, pipeline drugs, and specialty trend drivers
• Support clinical discussions and clinical program recommendations

Clinical Resource & Operational Support

• Serve as a clinical subject matter expert for pharmacy technicians and operations teams
• Provide guidance on complex medication cases and high-cost therapies
• Assist with training on criteria updates and program enhancements
• Performs other duties as assigned

Vendor & PBM Collaboration

• Partner with PBM clinical teams to ensure accurate execution of criteria
• Review PBM performance metrics related to prior authorization and utilization management
• Assist in identifying gaps or inconsistencies in PBM clinical application

Qualifications

Required

• Doctor of Pharmacy (PharmD)
• Active, unrestricted pharmacist license in good standing
• 2 years of clinical pharmacy experience (managed care, PBM, specialty, or retail)
• Strong knowledge of utilization management tools (PA, step therapy, quantity limits)

Preferred

• Experience reviewing prior authorizations
• Experience developing clinical criteria

Key Competencies

• Strong clinical judgment and analytical skills
• Ability to balance clinical appropriateness with financial stewardship
• Excellent written documentation skills
• Detail-oriented with strong time management abilities
• Ability to work collaboratively across clinical and operational teams
• Ability to balance clinical appropriateness with financial stewardship
• Strategic thinker who can move between individual case review and population-level impact

Physical Requirements (Essential Functions)

• Ability to remain in a stationary position (sitting or standing) for prolonged periods while reviewing clinical documentation and adjudicating cases.
• Ability to operate standard office and computer equipment, including keyboard, mouse, telephone, and workstation tools.
• Ability to communicate effectively in both verbal and written formats.
• Sufficient visual acuity to review electronic medication records, clinical documentation, and system tools.
• Occasional movement throughout the office to attend meetings or collaborate with colleagues.
• Occasional lifting or movement of office items or materials up to 20–25 pounds.

Work Environment

• Primarily a professional office environment located at 1701 Barrett Lakes Blvd, Suite 150, Kennesaw, GA.
• Hybrid or remote flexibility may be available based on departmental needs.
• Work involves extensive computer and telephone use.
• Noise level is generally low to moderate.

Schedule & Other Requirements

• May occasionally be required to work beyond standard business hours.
• Occasional travel may be required for vendor meetings, conferences, or operational oversight.
• Must be able to perform essential job functions with or without reasonable accommodations.