Clinical Pharmacist, PBM Utilization Management

Job Description

Location: Denver, CO (Onsite)

We are seeking a Clinical Pharmacist, PBM Utilization Management to develop utilization management criteria, support formulary strategy, and drive clinical program development. This position is a full-time, direct hire opportunity based in Denver, CO.

This role is best aligned for a PharmD with managed care or PBM experience who enjoys the analytical side of pharmacy practice. You will write the prior authorization and step therapy criteria that govern specialty coverage, run clinical drug reviews, adjudicate appeals for clinical appropriateness, and build the monographs and therapeutic class reviews that P&T committees decide from. The ideal candidate reads clinical evidence critically and turns it into policy that is defensible to prescribers, regulators, and finance alike.

Responsibilities:

• Develop prior authorization criteria for specialty and high-cost medications based on clinical evidence and FDA labeling
• Conduct clinical drug reviews and therapeutic assessments to support formulary recommendations
• Evaluate new medications for formulary placement, step therapy requirements, and quantity limits
• Perform drug utilization reviews to identify adherence trends, inappropriate use, and intervention opportunities
• Review prior authorization appeals and coverage exception requests for clinical appropriateness
• Support development of clinical pharmacy programs focused on adherence, therapeutic substitution, and specialty drug management
• Collaborate with medical directors and clinical leadership on pharmacy benefit policy and guideline development
• Support CMS Part D activities including formulary requirements, exceptions, appeals, and medication therapy management
• Prepare clinical monographs, therapeutic class reviews, and alternative therapy analyses for committee review
• Monitor drug pipeline updates, clinical guidelines, and emerging evidence to inform utilization management strategy
• Partner with cross-functional teams to support compliant and clinically sound utilization management processes
• Maintain accurate documentation of clinical reviews, recommendations, and policy decisions

Qualifications:

• Doctor of Pharmacy from an accredited college of pharmacy required
• Active, unrestricted Colorado pharmacist license required, or eligibility to obtain prior to start; multi-state licensure preferred
• Minimum of 3 years of experience in PBM, managed care pharmacy, or health plan pharmacy operations required
• Strong working knowledge of utilization management, prior authorization criteria development, formulary management, and drug utilization review required
• Familiarity with CMS Part D requirements, medication therapy management, and specialty pharmacy operations
• Demonstrated experience evaluating clinical evidence and presenting recommendations for formulary or P&T committee review
• Board certification such as BCPS or BCACP preferred
• Strong analytical, written communication, and documentation skills

Schedule:

• Full-time position
• On-site in Denver, CO
• Monday through Friday, standard business hours
• Standard full-time schedule of 40 hours per week

Salary Range: The salary range for this position is approximately $130,000 – $155,000 annually ($62.50 – $74.52 per hour), based on experience and qualifications.

Interview Process:

Selected candidates will participate in a multi-step interview process, including an initial screening with TalentLNX followed by interviews with department leadership.

Equal Opportunity Employer: TalentLNX is committed to equal employment opportunity and a diverse, inclusive workforce. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.