Description
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.
Position Summary The Academic Detailer/Clinical Advisor is a unique and high-impact pharmacist role combining clinical expertise, Medicare knowledge, data insights, and provider-facing communication skills. In this role, you will partner directly with a Medicare Advantage Health Plan to optimize formulary utilization, guide providers through preferred product selection, and support members in receiving the safest, most cost-effective therapies.
You will serve as a front-line clinical expert—educating prescribers, influencing prescribing behavior, identifying cost and quality opportunities, and ensuring the drug benefit is delivered in a clinically sound and financially responsible manner. This includes leveraging data, engaging directly with physicians, and aligning PBM and health plan strategies to drive superior outcomes.
This role is ideal for a pharmacist with PBM or health plan experience, strong knowledge of Medicare Part D rules, and exceptional communication and analytical skills.
This is a remote role, open to qualified candidates within the United States. Candidate must be willing and able to travel up to 40% of the time to meet business needs.
Key Responsibilities Clinical Strategy & Formulary Optimization
- Serve as the clinical subject matter expert for Medicare Part D formulary, utilization management, and preferred product strategy.
- Analyze drug utilization, trends, prescriber behavior, and savings opportunities at the plan, provider, and member level.
- Identify and implement strategies to drive preferred product adoption, biosimilar conversion, generic utilization, and gross-to-net optimization.
- Translate complex rebate, pricing, and utilization concepts into clear recommendations for both providers and health plan partners.
Provider Engagement & Academic Detailing
- Conduct direct outreach to prescribers via phone, virtual sessions, and in-person visits to influence safe, cost-effective prescribing.
- Deliver concise clinical messages on preferred alternatives, formulary pathways, safety considerations, and affordability.
- Educate providers on coverage determination processes, PA submissions, documentation requirements, and Medicare rules.
- Build strong relationships with prescribers, provider groups, and health plan clinical teams to reduce avoidable denials and improve member experience.
Medicare Part D & Utilization Management Expertise
- Apply expert-level understanding of CMS guidelines, HPMS memos transition rules, tiering exceptions, and benefit requirements.
- Support providers in navigating Coverage Determinations (CDs), Prior Authorizations (PAs), redeterminations, and appeals.
- Assist in the identification and correction of common PA submission patterns that lead to denials.
Data Interpretation & Reporting
- Partner with analytics teams to develop and deliver monthly, quarterly, and annual clinical reporting for the Health Plan.
- Use internal reporting tools (e.g., analytics dashboards, claims systems) to produce actionable insights.
- Present clinical and financial outcomes to health plan and PBM leadership, showcasing progress and impact.
Cross-Functional Collaboration
- Work closely with PBM stakeholders, health plan pharmacy leadership, FWA teams, formulary operations, specialty teams, and network partners.
- Identify opportunities to reduce fraud, waste, and abuse and improve overall drug program performance.
- Participate in strategy meetings, benefit reviews, provider initiatives, and clinical program deployment.
Leadership & Representation
- Represent Caremark and the Health Plan in provider meetings, care team discussions, and cross-functional initiatives.
- Support implementation of new clinical programs, benefit changes, and formulary updates.
- Travel for onsite provider visits, health plan meetings, and targeted field engagement as required (up to 40%).
Required Qualifications
- Active, unrestricted pharmacist licensure
- 5+ years of clinical experience, ideally including at least 1 year in a PBM, Health Plan, or Managed Care residency program.
- Strong demonstrated understanding of Medicare Part D benefit design, UM criteria, coverage determinations, and formulary management.
- Exceptional oral, written, and interpersonal communication skills.
- Proficiency in Microsoft tools and comfort working with data, dashboards, and reporting systems.
- Ability to travel up to 40% for provider engagement and onsite Health Plan needs.
Preferred Qualifications
- 3+ years direct experience in PBM, Health Plan, or Managed Care pharmacy in a client-facing role.
- Experience influencing prescribers, conducting academic detailing, or leading provider education initiatives.
- Strong analytical skills with ability to explain net cost, rebates, preferred product strategy, and clinical impact in simple terms.
- Ability to manage multiple high-visibility projects simultaneously and work autonomously.
- Familiarity with AMCP frameworks; AMCP Fundamentals of Managed Care Pharmacy Certificate strongly preferred.
- Comfort preparing provider-facing materials, clinical talking points, or formulary change communications.