Clinical Operations Advisor

Job DescriptionThe Pharmacist - Clinical Operations Advisor is a client facing role accountable for the design of the client formulary and utilization management programs in partnership the Health Plan (HP) Clinical Advisor, Benefit Relationship Manager, and Formulary Administration.The Clinical Operations Advisor collaborates with HPClinical Advisor to understand the client's clinical strategyand roadmap to create a clinical operations plan. TheClinical Operations Advisor works with the BenefitRelationship Manager and client to facilitate gatheringformulary and utilization management requirements anddesigns the drug level set up for projects on the operationsplan while ensuring compliance to internal best practiceand federal and state guidelines. This includes:o Completing the clinical data analysis to design anoptimal formulary and utilization managemento Collaborating with the Benefit Relationship Manager andFormulary Administration to clarify client clinicalrequirements to design and develop formulary andutilization management editso Reviewing and obtaining approval from client on thedesign of formulary and utilization managemento Consulting and influencing the client on standard andcustom formulary options and utilization management editso Reviewing identified defects during testing and helping toresolve these defects, including consulting with the clientto re-define and clarify the clinical requirementso Collaborating with internal partners to developautomation strategies and perform user acceptance testingas requiredo Ensuring timely delivery of formulary and utilizationmanagement edits, including reviewing the test results withthe cliento Meeting and/or exceeding CVSH yearly goals, includingmeeting and/or exceeding client service levels forturnaround times and accuracyo Consulting with clients and developing a trustedconsultative partnership that drives up client satisfactionThe Clinical Operations Advisor designs the clinical setups using Caremark technology solutions and supports thecoding teams in the loading of clinical data into theadjudication system (RxClaim). The Clinical OperationsAdvisor partners with clinical team members to documentclinical design best practices, provide inputs to streamlineprocesses, and identify opportunities to improve the efficiency and accuracy of clinical set ups.The Clinical Operational Advisor supports internal and client audits of clinical set ups within adjudication systems, which includes verifying the client approved requirements and design.The Clinical Operations Advisor should be able to manage multiple HP clients across multiple lines of business including Medicare, Medicaid, Exchange, and Commercial. This position can be located in a Corporate Hub or has the ability to work remotely/work from home within the U.S. Clinical Operations.This is a remote-based role, but the Advisor must have the ability to travel up to 30% of the time as needed.Required Qualifications- Must have the ability to travel up to 30% of the time.- 2+ years PBM or other managed care experience- 3+ years as a clinical pharmacist, data analytical role and/or experience working as a consultative pharmacist - Registered Pharmacist with current license in state of residenceCOVID RequirementsCOVID-19 Vaccination RequirementCVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated. You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.Preferred Qualifications- Client facing consultant experience- Experience with RxClaim- Data analytics skills, including data visualization and advanced profiency in MS Excel and/or MS AccessEducationRegistered Pharmacist in with current licenseB.S. or Doctorate of Pharmacy (PharmD) degree is required.Business OverviewBring your heart to CVS HealthEvery one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

Created: 2025-11-15