Make an Impact Where Clinical Excellence Meets Managed Care

Western Health Advantage is seeking a highly skilled Clinical Pharmacist to support our Medical Management – Pharmacy team. This role is ideal for a pharmacist who thrives at the intersection of clinical rigor, regulatory compliance, and operational excellence.

This position primarily supports Prior Authorization (PA) operations, ensuring timely, compliant, and clinically sound coverage determinations while contributing to formulary oversight, quality improvement, and pharmacy program optimization.

This opportunity offers up to 32 hours per week, providing meaningful clinical impact within a collaborative managed care environment.
 

What You’ll Do

Prior Authorization & Clinical Review

• Perform clinical review of outpatient and specialty medication PA requests.

• Ensure compliance with NCQA, Knox-Keene, DMHC, Board of Pharmacy, and other regulatory requirements.

• Apply evidence-based guidelines and credible drug information resources to coverage determinations.

• Provide clinical support for appeals and grievances.

• Communicate decision rationale clearly and professionally to network providers and internal stakeholders.

Formulary & Pharmacy Program Oversight

• Contribute to formulary development activities across multiple lines of business.

• Collaborate with the Pharmacy Oversight Committee (POC) and review PBM P&T committee outputs.

• Audit and update formulary documents and PA criteria.

• Monitor PBM P&T changes to ensure compliance with Western Health Advantage policies and regulatory standards.

• Manage new-to-market products and National Drug Codes (NDCs).

Quality & Operational Excellence

• Analyze pharmacy cost-of-care trends and support development of appropriate use protocols.

• Participate in clinical quality improvement initiatives.

• Support accreditation readiness (DMHC, NCQA).

• Contribute to workflow optimization, system upgrades, and operational readiness planning.

• Provide cross-coverage support during peak seasons, PTO, and emergent staffing needs.

What You Bring

Required Qualifications

• Doctor of Pharmacy (PharmD) or equivalent education meeting California licensure requirements.

• Active, unrestricted California Pharmacist license in good standing.

• Minimum four (4) years of retail, mail order, or hospital pharmacy experience.

• Strong proficiency in evaluating drug literature, clinical trial data, and evidence-based resources (e.g., UpToDate, DrugDex, NCCN).

• Excellent written communication skills appropriate for clinical and business correspondence.

Preferred Qualifications

• Managed care, PBM, health plan, or delegated medical group experience (2+ years preferred).

• Experience writing drug monographs or prior authorization criteria.

• Formulary management experience.

• Strong clinical and analytical background in specialty medications.

• Residency training.
  
   

  Western Health Advantage is committed to providing equal employment opportunities to employees and applicants for employment on the basis of merit and without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, physical or mental disability, medical condition, genetic information, marital status, ancestry, military or veteran status, or any other basis made unlawful by federal or state law.

  Western Health Advantage values and supports the unique talents and strengths that each employee brings to our organization. Collaborating with the best and the brightest means a dynamic, fulfilling work experience for you — and excellent customer service for our members.