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)