Clinical Pharmacist I - Medicare Part D / Prior Auth (Remote | M-F, 8am-5pm Pacific)
About The Position
Alignment Health is seeking a Clinical Pharmacist I to join its pharmacy team in a fully remote, full-production managed care pharmacy role supporting Medicare Part D members. The position primarily handles Part D prior authorization, coverage determination, appeal reviews, and Medication Therapy Management (MTM) activities. The pharmacist applies clinical judgment, plan benefits, and CMS requirements to deliver timely, compliant coverage decisions and medication reviews for Alignment Health Plan members. The pharmacist serves as a subject matter expert in Part D coverage determinations and redeterminations, as well as Part C organizational determinations. MTM work includes comprehensive medication reviews and targeted interventions, particularly for high-risk members, with the aim of improving adherence, reducing high-risk medication utilization, and enhancing quality of care. The role also supports pharmacy quality, compliance, and other managed-care functions and projects as assigned. The standard schedule is Monday through Friday, 8:00 AM–5:00 PM Pacific Time. Rotational weekend coverage is required based on business needs and case volume, currently approximately every four to five weeks. The role requires an active, unrestricted pharmacist license in at least one U.S. state and at least one year of health plan, PBM, or managed-care pharmacy experience.
Requirements
- At least one year of experience working at a health plan, Pharmacy Benefit Manager (PBM), or in a managed-care pharmacy setting.
- Bachelor’s degree in Pharmacy or a related health science field.
- Active, unrestricted pharmacist license in at least one U.S. state.
- Knowledge of CMS Medicare Part D coverage determination and appeal processes, CDAG timelines, and formulary exception criteria.
- Proficiency in conducting comprehensive and targeted medication therapy reviews; familiarity with MTM platforms and documentation requirements.
- Ability to evaluate clinical literature, formulary criteria, and prescribing guidelines to make compliant, defensible coverage decisions.
- Experience navigating PBM adjudication platforms, pharmacy management software, and claims-related systems.
- Working knowledge of CMS regulations, HIPAA, and Medicare Advantage plan compliance requirements.
- Ability to interpret and produce pharmacy-related reports, clinical correspondence, and coverage decision letters.
- Competence with mathematical calculations, statistical interpretation, and using data to support quality and operational decisions.
- Availability for rotational weekend shifts as needed.
Nice To Haves
- Doctor of Pharmacy (PharmD), master’s degree, or PhD in Pharmacy; an equivalent combination of relevant education and demonstrated clinical experience may be considered.
- Experience applying clinical decision-making in a regulated, compliance-driven healthcare environment, preferably at enterprise scale.
- Exposure to Medicare Part D operations, formulary management, or utilization management.
- Experience in Medicare Part D prior authorization, coverage determinations, appeals or redeterminations, pharmacy utilization management, or CDAG within a Medicare Advantage health plan.
- Medication Therapy Management experience, including CMR delivery and documentation in an MTM platform.
- Experience with CMR/TMR, formulary exceptions, B vs. D determinations, quantity limits, step therapy, and other Medicare Part D pharmacy operations.
- Bilingual English/Spanish.
Responsibilities
- Review and render Part D coverage determination and appeal requests using clinical judgment, plan benefits, and CMS requirements.
- Collaborate with medical directors by providing clinical information needed for reviews in accordance with applicable guidelines.
- Conduct telephone-based comprehensive medication reviews for members enrolled in the MTM program.
- Identify drug therapy problems, optimize medication regimens for complex patients, and develop actionable medication action plans.
- Perform Care for Older Adults Medication Reviews (COA-MDR) to support Stars quality measures and improve outcomes for the plan’s senior population.
- Participate in pharmacy quality improvement projects aligned with Medicare Star Ratings, HEDIS measures, and internal clinical standards.
- Help identify gaps in care and contribute clinical expertise to improve member safety metrics, adherence rates, and overall plan performance.
- Maintain records of clinical reviews, coverage determinations, and consultations in accordance with CMS timelines and organizational standards.
- Comply with regulatory frameworks governing Medicare Part D, including CMS guidelines on coverage determinations, appeals, and grievances (CDAG).
- Support additional managed-care functions and projects and perform other duties as assigned.
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What This Job Offers
Job Type
Full-time
