Clinical Pharmacist I - Remote

This position is remote.

The Clinical Pharmacist I is responsible for reviewing coverage determinations and appeals to ensure clinical appropriateness and compliance with CMS regulations and plan benefits for Alignment Health Plan (AHP) members. This role serves as a subject matter expert in Part D coverage determinations, redeterminations, and Part C organizational determinations. In addition, the Clinical Pharmacist I conducts Medication Therapy Management (MTM) activities, including comprehensive medication reviews (CMRs) and targeted interventions, with a focus on high-risk members to improve adherence, reduce high-risk medication utilization, and enhance overall quality of care for AHP members. The Clinical Pharmacist I supports additional managed care functions and projects as assigned.

Job Responsibilities

• Drive
• Accurate and
• Timely
• Part
• D
• Coverage
• Decisions: Review and render Part D coverage determination and appeal requests, applying clinical judgment against plan benefits and CMS requirements to render compliant decisions. Collaborate with medical directors by providing appropriate clinincal information needed to perform clinincal reviews per the guidelines.
• Deliver
• Medication
• Therapy
• Management
• Services: Conduct comprehensive medication reviews via telephone for members enrolled in the MTM program, identifying drug therapy problems, optimizing regimens for complex patients, and developing actionable medication action plans. Perform the Care for Older Adults Medication Review (COA-MDR) to support Stars quality measure performance and proactively improve outcomes for the plan's senior population.
• Advance
• Pharmacy
• Quality and
• Compliance
• Initiatives: Participate in pharmacy quality improvement projects aligned with Medicare Star Ratings, HEDIS measures, and internal clinical standards. Support the identification of gaps in care and contribute clinical expertise to initiatives that improve member safety metrics, adherence rates, and overall plan performance.
• Ensure
• Regulatory and
• Documentation
• Integrity: Maintain appropriate records of all clinical reviews, coverage determinations, and consultations in accordance with CMS timelines and organizational standards. Adhere to all regulatory frameworks governing Medicare Part D, including CMS guidelines on coverage determinations, appeals, and grievances (CDAG).
• Other duties and projects not listed above

Job Requirements

Experience

• Required: Minimum of 1 year of experience working at a health plan, Pharmacy Benefit Manager (PBM), or in a managed care pharmacy setting.
• Preferred: Demonstrated experience applying clinical decision-making in a regulated, compliance-driven healthcare environment (enterprise-scale preferred). Exposure to Medicare Part D operations, formulary management, or utilization management strongly expected.

Education

• Required: Bachelor's degree in Pharmacy or a related health science field
• Preferred: Doctor of Pharmacy (PharmD), Master's degree, or PhD in Pharmacy. Equivalent combination of relevant education and demonstrated clinical experience will be considered

Licensure

• Required: Active and unrestricted Pharmacist license in the applicable state(s)

Skills & Competencies

• Part
• D
• Regulatory &
• Formulary
• Knowledge (Intermediate): In-depth understanding of CMS Medicare Part D coverage determination and appeal processes, CDAG timelines, and formulary exception criteria.
• Medication
• Therapy
• Management (Intermediate): Proficiency in conducting CMR and TMR reviews; familiarity with MTM platforms and documentation requirements.
• Clinical
• Decision-Making &
• Evidence
• Application (Intermediate): Ability to evaluate clinical literature, formulary criteria, and prescribing guidelines to make compliant, defensible coverage decisions.
• Pharmacy
• Benefit
• Management
• Systems (Intermediate): Experience navigating PBM adjudication platforms, pharmacy management software, and claims-related systems.
• Healthcare
• Regulatory
• Compliance (Intermediate): Working knowledge of CMS regulations, HIPAA, and Medicare Advantage plan compliance requirements.
• Medical
• Documentation &
• Reporting (Intermediate): Ability to comprehend, interpret, and produce pharmacy-related reports, clinical correspondence, and coverage decision letters.
• Data
• Interpretation &
• Basic
• Analytics (Basic): Competence with mathematical calculations, statistical interpretation, and using data to support quality and operational decision-making.

Preferred Qualifications

• Prior experience specifically in CDAG (coverage determinations, appeals, and grievances) within a Medicare Advantage health plan environment.
• Previous Medication Therapy Management experience, including CMR delivery and documentation in an MTM platform
• Bilingual (English/Spanish) — an asset in serving diverse Medicare Advantage member populations.

Other

• Standard work schedule: Monday through Friday, 8 AM – 5 PM PST, with availability for rotational weekend shifts as needed.

Essential Physical Functions

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Pay Range

$113,332.00 - $169,999.00

Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*disclaimer

Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/ [https://protect-us.mimecast.com/s/P1GaC82l6KF8ygOUngCFQ/]. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email careers@ahcusa.com [careers@ahcusa.com].