Pharmacist, Utilization Management

@ Molina Healthcare

About the Role

The Pharmacist, Utilization Management at Molina Healthcare ensures that members have access to all medically necessary prescription drugs in a cost-effective and safe manner. The role involves creating, operating, and monitoring pharmacy benefit programs in line with federal and state laws.

Key Responsibilities

• Review coverage determinations and appeals accurately and timely.
• Serve as a formulary and drug information resource.
• Assist call center pharmacy technicians and answer clinical drug questions.
• Collaborate with medical directors and leadership on quality and cost initiatives.
• Lead and support pharmacy call center teams when delegated.
• Engage in projects to improve quality metrics such as Star ratings, HEDIS, and CAHPS.
• Perform outreach to patients and physicians to drive quality and clinical outcomes.

Knowledge, Skills, and Abilities

• Expertise in formulary management and drug information.
• Ability to comply with coverage determinations and appeals procedures.
• Solid understanding of pharmacy cost control initiatives and quality metrics.
• Strong communication skills for interfacing with members, providers, pharmacies, and internal teams.

Qualifications

Doctor of Pharmacy or bachelor’s degree in Pharmacy with equivalent experience; 1-2 years post-graduate experience; active, unrestricted State Pharmacy License; Medicare Part D, Medicaid or managed care experience preferred.

Key skills/competency

• Pharmacy
• Utilization Management
• Formulary
• Cost Control
• Quality Metrics
• Clinical Review
• Drug Utilization
• Patient Outreach
• Call Center
• Team Leadership