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 for its pharmacy team. This is a fully remote, full-production managed care pharmacy role supporting Medicare Part D members. The pharmacist reviews Part D prior authorization requests, coverage determinations, and appeals, applying clinical judgment, plan benefits, and CMS requirements to make timely, compliant decisions. The role is a subject matter expert in Part D coverage determinations and redeterminations, as well as Part C organizational determinations, and collaborates with medical directors by providing clinical information for reviews. The pharmacist also delivers Medication Therapy Management (MTM) services, including telephone-based comprehensive medication reviews (CMRs), targeted interventions, and Care for Older Adults Medication Reviews. The work focuses on identifying drug therapy problems, optimizing medication regimens, improving adherence, reducing high-risk medication utilization, and supporting quality outcomes for Alignment Health Plan members. The role contributes to pharmacy quality initiatives and other managed-care functions and projects as assigned. The standard schedule is Monday through Friday, 8:00 AM–5:00 PM Pacific Time, with rotational weekend coverage required based on business needs and case volume, currently approximately every 4–5 weeks.
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.
- In-depth understanding of CMS Medicare Part D coverage determination and appeal processes, CDAG timelines, and formulary exception criteria.
- Proficiency in conducting CMR and TMR reviews, with 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 the stated weekday schedule and rotational weekend shifts as needed.
Nice To Haves
- Experience applying clinical decision-making in a regulated, compliance-driven healthcare environment; enterprise-scale experience is preferred.
- Exposure to Medicare Part D operations, formulary management, or utilization management.
- Experience with Medicare Part D prior authorization, coverage determinations, appeals or redeterminations, pharmacy utilization management, formulary exceptions, B versus D determinations, quantity limits, or step therapy.
- Doctor of Pharmacy (PharmD), Master's degree, or PhD in Pharmacy; equivalent combinations of relevant education and demonstrated clinical experience will be considered.
- Prior CDAG experience within a Medicare Advantage health plan.
- Medication Therapy Management experience, including CMR delivery and documentation in an MTM platform.
- Bilingual English/Spanish.
Responsibilities
- Review and render Part D coverage determination and appeal decisions using clinical judgment, plan benefits, and CMS requirements.
- Collaborate with medical directors by providing clinical information needed to perform reviews under applicable guidelines.
- Conduct telephone-based comprehensive medication reviews for members enrolled in the MTM program.
- Identify drug therapy problems, optimize regimens for complex patients, and develop actionable medication action plans.
- Perform Care for Older Adults Medication Reviews to support Stars quality measure performance and improve outcomes for senior members.
- 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, adherence, and plan performance.
- Maintain records of clinical reviews, coverage determinations, and consultations in accordance with CMS timelines and organizational standards.
- Follow regulatory frameworks governing Medicare Part D, including CMS guidelines for 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
