Company Overview
As a Clinical Pharmacist Reviewer, you will evaluate formulary exceptions, prior authorizations, and quantity limit override requests submitted by providers—via phone and fax—across various benefit areas, including Retail Pharmacy, Medicare Advantage Part D, Home Infusion Therapy, and Medical Utilization Management.
Key Responsibilities
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Review and manage Prior Authorizations, Formulary Exceptions, Step Therapy, and Quality Care Dosing programs.
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Support compliance and timely determinations across product lines, including Medicare Part D (some weekend/holiday rotation required).
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Collaborate on Home Infusion Therapy and Specialty Pharmacy programs.
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Train staff and lead presentations in partnership with clinical and non-clinical teams.
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Contribute to drug utilization and clinical program development.
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Lead special projects and provide clinical guidance to internal/external stakeholders.
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Troubleshoot issues raised by MAPS, Health Management, IT, PBM teams, and customer service.
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Identify workflow improvements and recommend new quality and cost-saving initiatives.
Qualifications
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Registered Pharmacist (RPh or PharmD) from an accredited program.
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Valid, unrestricted license to practice pharmacy in Massachusetts (or applicable state).
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Experience in managed care or PBM setting required.
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Supervision of clinical or operational teams preferred.
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Proficient in Microsoft Office and pharmacy systems.
Skills
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Strong written and verbal communication
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Effective collaboration and presentation skills
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Detail-oriented with excellent time management
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Analytical and problem-solving abilities
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Results-driven with a proactive mindset
Why Join Blue Cross Blue Shield of Massachusetts?
At Blue Cross MA, we value diverse perspectives and are committed to fostering an inclusive, supportive workplace. We understand the confidence gap and imposter syndrome and encourage you to apply even if you don’t meet every requirement—we want to hear from you. Together, we can transform healthcare for all.
Compensation & Benefits
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Competitive salary with potential for variable pay
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Paid time off, 401(k), and comprehensive medical/dental/vision coverage
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A range of wellness and development resources to support your career and work-life balance
Join our Talent Community or visit our Company Culture and How We Work pages to learn more.