RUHMA KHAN
Summary
Licensed Pharmacist and PGY1 Managed Care Pharmacy Resident at MetroPlus Health Plan with a strong focus in utilization management, prior authorization (PA), and pharmacy benefit management (PBM). Demonstrates leadership in evaluating complex pharmacy and medical claims across Medicare, Medicaid, and Commercial lines using FDA labeling, clinical guidelines, and NCD/LCD criteria to drive clinically appropriate, cost-effective coverage decisions.
Experienced in developing and optimizing clinical coverage policies, step therapy protocols, and GPI-based adjudication logic, including creation of evidence-based denial rationales and audit-ready documentation. Proven ability to improve medication access and streamline authorization workflows by identifying formulary alternatives and aligning coverage criteria with evidence-based treatment standards.
Brings a data-driven and patient-centered approach to managed care, with strong clinical judgment in assessing therapy plans, identifying cost-saving opportunities, and supporting population health initiatives across diverse populations, including Medicare, HIV, and behavioral health. Detail-oriented and highly organized with strong time management skills, and a collaborative communicator focused on improving outcomes, operational efficiency, and access to care.
Overview
3
3
years of professional experience
1
1
Certification
Work History
Per Diem Pharmacist
Shift RX
New York, New York
12.2025 - Current
- Verify and dispense prescriptions while ensuring safe, accurate, and compliant medication processing in a community pharmacy setting.
- Counsel patients on prescription medications, over-the-counter therapies, immunizations, and adherence strategies to optimize medication use.
- Conduct drug utilization reviews to identify interactions, therapeutic duplications, inappropriate dosing, and other medication safety concerns.
- Troubleshoot insurance rejections, pharmacy claims issues, and prior authorization barriers by collaborating with prescribers, patients, and pharmacy benefit plans.
- Review medication profiles and clinical history to support appropriate therapy selection, continuity of care, and improved patient outcomes.
PGY-1 Managed Care Pharmacy Resident
NYC Health + Hospitals (Metro Plus Health)
New York, NY
09.2025 - Current
- Conduct comprehensive clinical reviews of prior authorization (PA) requests across Medicare, Medicaid, and Commercial lines using FDA labeling, clinical guidelines, and evidence-based criteria; evaluate labs, diagnoses, and treatment history to support accurate and timely determinations.
- Utilize clinical and PBM systems (EPIC, DCMS, CVS Caremark CAS, RxClaim, CVS Client Care Services) to review patient profiles, medication history, and claims data to inform coverage decisions and ensure audit-ready documentation.
- Develop and implement clinical coverage policies, prior authorization criteria, and step therapy protocols for specialty and high-cost medications, integrating FDA guidance, clinical trial data, and payer benchmarks.
- Design and optimize GPI-based utilization management strategies, including step therapy and quantity limits, to support appropriate therapy sequencing and cost-effective formulary management.
- Translate clinical coverage criteria into system-based adjudication logic to support automated step therapy edits and consistent claims processing.
- Perform Independent Benefit Review (IBR) case evaluations and develop clear, evidence-based denial rationales while identifying clinically appropriate alternative therapies.
- Interpret and apply Medicare Part B/Part D requirements, NCD/LCD criteria, and Medicaid guidelines to ensure compliant and clinically appropriate coverage determinations.
- Prepare drug monographs, therapeutic class reviews, and clinical evaluations to support Pharmacy & Therapeutics (P&T) Committee formulary decision-making and formulary strategy.
- Evaluate pipeline and newly approved therapies to inform formulary positioning, coverage decisions, and strategic drug management initiatives.
- Conduct Care Opportunity Assessments (COAs) and Comprehensive Medication Reviews (CMRs/MTM) by analyzing pharmacy and medical claims, diagnoses, and medication profiles to identify therapy gaps, adherence issues, and optimization opportunities.
- Manage and optimize medication therapy for diverse patient populations, including Medicare beneficiaries, HIV, behavioral health, and complex chronic disease populations, supporting programs such as MAP/UltraCare models of care.
- Collaborate with physicians, nurses, and interdisciplinary teams to obtain clinical documentation, resolve complex cases, and optimize medication therapy.
- Monitor PA performance metrics (e.g., turnaround time, approval rates) and lead workflow improvements to enhance operational efficiency and compliance with service level agreements (SLAs).
- Support formulary management and cost-containment strategies through evaluation of biosimilars, therapeutic alternatives, and site-of-care optimization initiatives.
- Participate in population health programs (e.g., HIV, Hepatitis C, behavioral health) to evaluate utilization, adherence, and outcomes and improve overall care delivery.
- Ensure compliance with CMS, Medicaid, and internal audit requirements through accurate, policy-aligned documentation and adherence to utilization management standards.
- Led optimization of CHP step therapy formulary by removing clinically inappropriate step requirements and aligning criteria with guideline-based treatment sequencing, improving patient access while maintaining cost-effective utilization management.
Pharmacy Intern
Marhaba Pharmacy
New York, NY
01.2025 - 06.2025
- Counseled patients on prescription and OTC medications.
- Supported MTM and adherence programs.
- Conducted prescription verification and data entry.
- Assisted with inventory management.
- Supported immunization administration.
- Collaborated with healthcare providers.
Pharmacy Intern
MetroPlus Health
New York, NY
01.2024 - 05.2024
- Assisted pharmacists in reviewing prior authorization requests and supporting utilization management activities for specialty and high-cost medications.
- Supported the development and review of clinical coverage policies by conducting literature searches using FDA labeling and drug information resources.
- Participated in Care Opportunity Assessments (COAs) by reviewing pharmacy claims and medication histories to identify potential therapy gaps.
- Assisted in preparing drug information summaries and clinical materials for internal review and Pharmacy and Therapeutics (P&T) committee discussions.
- Observed managed care pharmacy operations including formulary management, pharmacy claims review, and coverage determination processes.
Pharmacy Intern
Enexia Specialty Pharmacy
New York, NY
09.2023 - 10.2023
- Prepared sterile IV and injection products under USP 797.
- Organized sterile prep batches.
Education
Doctor of Pharmacy - Pharm.D.
PharmD, LIU Pharmacy — The Arnold & Marie Schwartz College
NY 08.2021 - 06/2025
Skills
- Inventory Management
- Microsoft Office (Word, Excel, SharePoint)
- Patient Counseling
- Immunizations
- MTM & DUR
- Medication Adherence Support
- Interdisciplinary Team Collaboration
- Pharmacy Benefit Management (PBM)
- Adherence monitoring and gap-in-care identification
- Comprehensive Medication Reviews (CMR)
- Polypharmacy review and medication reconciliation
- Prior authorization (PA) criteria development and revision
- Pharmacy claims review and adjudication
- Formulary evaluation
- Data analysis
- Collaborative teamwork
- Specialty pharmacy knowledge
- Regulatory standards
- Quality assurance standards
- FDA drug safety guidelines
- Pharmacy operations management
- Medicare/Medicaid/Commercial Plans
- Detail oriented
- Time management
- Formulary management
Certification
- Licensed Pharmacist, New York
- Certified APhA Pharmacy-Based Immunization Delivery
- Certified CPR Certification, American Heart Association
- Naloxone Administration Trained
License
- Registered Pharmacist
- License# 073549
Timeline
Per Diem Pharmacist
Shift RX
12.2025 - Current
PGY-1 Managed Care Pharmacy Resident
NYC Health + Hospitals (Metro Plus Health)
09.2025 - Current
Pharmacy Intern
Marhaba Pharmacy
01.2025 - 06.2025
Pharmacy Intern
MetroPlus Health
01.2024 - 05.2024
Pharmacy Intern
Enexia Specialty Pharmacy
09.2023 - 10.2023
Doctor of Pharmacy - Pharm.D.
PharmD, LIU Pharmacy — The Arnold & Marie Schwartz College
08.2021 - 06/2025