Clinical Pharmacist (Pulse PBM)

About Us:

Revive is a dynamic and innovative organization specializing in healthcare delivery and technology. We pride ourselves on delivering exceptional products/services and building strong, long-lasting relationships with our valued clients.

The Clinical Pharmacist is the clinical voice of Pulse PBM, Revive Health's pharmacy benefit management business. This role partners with plan sponsors, brokers, and Revive pharmacy leadership to design, implement, and manage pharmacy benefits that deliver the lowest net cost while protecting and improving member outcomes. The Clinical Pharmacist reviews claims in real time, recommends therapeutic interchanges and other clinical savings opportunities, runs Pulse's cost containment programs, produces client reporting, and is part of the team that communicates directly with members, prescribers, and clients, including at quarterly business reviews.

Duties:

Client Implementation & Benefit Design

• Serve as the clinical lead on new client implementations, guiding plan sponsors and brokers through benefit design decisions such as formulary selection, utilization management, preventive coverage, and clinical program options.
• Review completed benefit design questionnaires and translate client decisions into clinical edits, prior authorization criteria, step therapy, and  quantity limits in the claims system.
• Analyze  prior-PBM claims and formulary data to assess member disruption, and recommend transition-of-care strategies before go-live.

Real-Time Claims Review & Clinical Optimization

• Monitor  pharmacy claims in real time to identify high-cost claims, inappropriate  utilization, safety concerns, and savings opportunities.
• Recommend therapeutic interchanges, generic and biosimilar alternatives, and other lower-net-cost options that maintain or improve clinical outcomes, and coordinate with prescribers and members to put changes in place.
• Analyze clinical reviews for prior authorizations, formulary exceptions, and coverage determinations according to plan criteria and render opinions or change recommendations.
• Conduct prospective, concurrent, and retrospective drug utilization review, and identify adherence and safety interventions such as opioid safety.

Cost Containment Programs

• Manage and execute Pulse cost-containment programs, including, but not limited to, international pharmacy, 340B, and manufacturer patient assistance programs. 
• Identify eligible members and medications, coordinate enrollment, and track program savings and member impact.
• Ensure programs operate in line with plan documents, applicable federal and state law, and manufacturer program terms.

Reporting & Analytics

• Generate clinical and financial reports for clients and internal leadership, covering utilization trends, cost drivers, specialty spend, program savings, and clinical outcomes.
• Analyze claims data to project trend and quantify the impact of recommended benefit or formulary changes.
• Prepare clinical content for and participate in quarterly business reviews with clients and brokers.

Client & Member Communication

• Act as a clinical point of contact for plan sponsors, brokers, TPAs, and  members, responding to clinical and coverage questions promptly and professionally.
• Communicate   with members and prescribers about therapy changes, program enrollment, and coverage decisions in clear, plain language.
• Draft  member and client communications such as formulary change notices and   program materials.

Collaboration & Strategy

• Work  closely with Revive pharmacy executives on clinical strategy, formulary management, pricing, and new program development.
• Partner with account management, operations, and the claims processor to resolve issues and improve workflows.
• Stay current on new drug approvals, the drug pipeline, guideline changes, and market events such as biosimilar launches and patent expirations, and  advise on their impact to clients.

Quality Assurance & Compliance

• Maintain accurate documentation of clinical reviews, interventions, and program activity.
• Ensure work complies with HIPAA, ERISA, the ACA, state pharmacy regulations, and internal policies.

• Doctor of Pharmacy (PharmD) from an ACPE-accredited college of pharmacy.
• Active, unrestricted pharmacist license in good standing, with the ability to obtain additional state licenses as required.
• Minimum  of 1 year of pharmacist experience in a PBM, managed care, health plan,  or clinical pharmacy setting; managed care residency (PGY1) or board  certification is a plus.
• Working knowledge of formulary management, utilization management, prior authorization criteria, and specialty pharmacy.
• Understanding of PBM economics (net cost, rebates, pricing, and pass-through models) and cost containment programs such as copay maximizer, 340B, and patient assistance programs.
• Strong analytical skills, including working with claims data and advanced Excel; experience with reporting or BI tools is a plus.
• Excellent written and verbal communication skills, with the ability to present to clients, brokers, and executives.
• Attention  to detail and the ability to manage multiple clients, deadlines, and priorities in a fast-paced environment.