Community Health Group is a locally based non-profit health plan that ensures access to high quality, culturally sensitive health care for underserved communities throughout San Diego County. We treat our 300-member, multi-lingual staff like family, encouraging an atmosphere of collaborative teamwork, continuous learning, personal growth, and promotion from within. Recognized as one of the Top Workplaces in San Diego, CHG offers its employees such benefits as tuition reimbursement, a meditation room and yoga classes, a monthly Breakfast With The CEO, and memorable events throughout the year. 

We know that by serving our employees well, they, in turn, will better serve our nearly 300,000+ membership. We have been recognized consistently for the excellence and sensitivity of our customer service by members, physicians, vendors, and a full range of health care providers. We are accredited by the National Committee for Quality Assurance and proud of our continuing company-wide Quality Initiatives.

We are currently recruiting for:



The focus of this position is three-fold:  provide timely, appropriate, and cost-effective drug therapy for health plan members by reviewing prior authorization and medical necessity requests; works to meet CMS regulatory requirements for Medicare Part D; and supports and develops clinical initiatives to achieve HEDIS goals.



Works closely with pharmacy staff and PBM to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including CMS and/or Medicare Part D and Medi-Cal as well accreditation standards such as NCQA.



  • Review prior authorization requests and make determinations for drug products according to member benefits and coverage criteria.   

  • Provide clinical guidance and support to the pharmacy technicians.

  • Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews

  • With the team, develops and implements clinical criteria for the review of non-formulary or non-preferred medications and clinical edits to adjudicate claims and enhance drug utilization

  • Assists in analyzing and researching pharmacy cost trends and clinical program opportunities in managing high-cost therapies.

  • Works to meet CMS regulatory requirements for Medicare Part D, including but not limited to compliance related to formulary administration, the Part D coverage determinations process, Medicare reporting, PDE resolution, Medicare medication safety and overutilization monitoring, and fraud, waste and abuse activities.

  • Work in collaboration with other departments to produce pharmacy related marketing materials in accordance with CMS guidelines. Produce marketing materials within internally determined timeframes with accuracy and in accordance with the CMS marketing guidelines.

  • Supports initiatives to achieve HEDIS targeted disease state goals related to drug therapy.

  • Takes a lead role in the implementation of new drug-related initiatives and the establishment of new clinical pharmacy services or initiatives as requested.

  • Contributes to the team effort, maintains customer confidence, protects operations, and identifies potential quality issues by attending department meetings; giving and receiving feedback.

  • Performs other duties and assignments as requested.



  • Must have a current and unrestricted California pharmacy license.

  • PharmD degree preferred

  • Minimum 1 year in managed care pharmacy; 3 years in retail or PBM experience preferred

  • Experience with Medi-Cal and Medicare preferred

  • Full working knowledge of Microsoft program

  • Knowledge of managed care principles, CPT, ICD-9, HCPCS coding, experience with medical review criteria preferred

  • Ability to communicate effectively verbally and in writing

  • Exceptional telephone and customer service skills

  • Ability to establish effective working relationships with physicians and medical professionals

  • Ability to organize work effectively, determine priorities, and work well independently



    Physical Requirements:   

  • Prolonged periods of sitting at desk; intermittent standing, walking, bending, stooping, lifting 10 lb. or less

  • Will be required to share on-call coverage

  • May be required to work evenings and/or weekends and holidays

  • May be necessary to work and attend meetings outside of facility or normal business hours