Clinical Pharmacist - CarelonRx

Anticipated End Date:

2026-05-11

Position Title:

Clinical Pharmacist - CarelonRx

Job Description:

Clinical Pharmacist – CarelonRx

Location: This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

CarelonRx is a proud member of the Elevance Health family of companies. CarelonRx pairs a strong, clinical-first lens with deep pharmacy expertise to create solutions that improve outcomes, control costs, and enhance each member’s health.

The Clinical Pharmacist will be responsible for managing the selection and utilization of pharmaceuticals and supporting core clinical programs such as DUR, UM, and formulary management.

How you will make an impact:

• Research and synthesize detailed clinical data related to pharmaceuticals.
• Serves as a clinical resource to other pharmacists on areas such as formulary, utilization management edits, DURs and coordinates with operations team to code programs to meet intent.
• Leads pharmacy claims adjudication configuration by translating formulary and utilization management requirements into claims processing rules/edits (including non-standard configurations), developing build specifications, and partnering with operations/coding teams to implement and validate expected claim outcomes.
• Interprets and operationalizes Medicaid/state requirements (e.g., state drug lists, coverage rules, and PA requirements) by creating clear clinical criteria and configuration documentation for PA and claims systems; provides independent oversight to ensure consistent, compliant program setup.

Minimum Requirements: 

• Requires a BA/BS in Pharmacy.
• Minimum of 2 years of managed care pharmacy (PBM) experience or residency in lieu of work experience; or any combination of education and experience, which would provide an equivalent background.
•  Requires a registered pharmacist.
• Current unrestricted Pharmacist license in applicable state(s) required.

Preferred Skills, Capabilities and Experiences:

• PharmD preferred.
• Demonstrated experience with pharmacy claims processing/adjudication logic and the ability to translate clinical intent into operational outcomes (e.g., PA, step therapy, quantity limits, DUR messaging, plan/benefit rule behavior).
• Proven ability to perform claims configuration/build support (including non-standard or exception configurations), partnering effectively with IT/operations/coding teams to implement, test, and validate expected claim results.
• Working knowledge of Medicaid/state program requirements (e.g., state PDL/drug list management, coverage rules, effective dating, compliance documentation) and experience operationalizing those requirements in claims and/or PA systems.
• Experience developing, maintaining, and communicating Prior Authorization clinical criteria in a format that can be operationalized by PA teams and configured in UM platforms; strong attention to clarity, consistency, and auditability.
• Strong requirements documentation skills—able to produce clear build specifications and decision logic in Excel and/or PDF (e.g., traceability from policy → configuration, test scenarios, effective dates), with disciplined version control.
• Demonstrated strength in cross-functional collaboration (clinical, PBM/claims operations, PA operations, coding/IT, compliance) with the ability to resolve ambiguity and drive decisions to closure.
• Ability to work independently, manage multiple concurrent initiatives, and prioritize effectively in a fast-changing environment with minimal supervision.
• Strong analytical and troubleshooting skills, including the ability to interpret claims outputs/reject messaging and related data extracts to identify root cause and recommend corrective action.

Job Level:

Non-Management Exempt

Workshift:

1st Shift (United States of America)

Job Family:

MED > Licensed/Registered Pharmacist/Pharmacy Technic