Pharmacist Clinical Senior - CarelonRx

Anticipated End Date:

2026-05-11

Position Title:

Pharmacist Clinical Senior - CarelonRx

Job Description:

Pharmacist Clinical Senior – 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 Pharmacist Clinical Senior will be responsible for developing and implementing pharmacy programs.

How you will make an impact:

• Provides clinical consulting services to clients, Sales, and Account Management and responsible for the implementation of clinical requirements and programs.
• Leads configuration and customization of formulary and utilization management that align with client intent.
• Communicates Pharmacy and Therapeutics (P&T) committee decisions as well as their impact on a client’s formulary.
• 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 4 years of experience as a pharmacist in a clinical setting; 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.
• Experience coaching/mentoring other pharmacists or analysts, providing guidance on formulary/UM edits, claims outcomes, and documentation standards to ensure consistent, high-quality delivery.
• 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.

Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel, or any embassy located in or outside of the US, unless they are command-sanctioned activities.

For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

For associates working within Puerto Rico who are member or patient-facing either in a clinical setting or in the Best Transportation unit, a current PR health certificate and a current PR Law 300 certificate are required for this position.

Job Level:

Non-Management Exempt

Workshift:

1st Shift (United States of America)

Job Family:

MED > Licensed/Registered Pharmacist/Pharmacy Technician

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.

NOTE: Workday keeps job postings active through 11:59:59 PM on the day before the listed end date. Example: If the end date is 3/13, the posting will automatically come down on 3/12 at 11:59:59 PM. In other words — the job is posted until 3/13, not through 3/13.