Remote Clinical Pharmacist I

Job Overview 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. 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. Job Responsibilities Drive Accurate and Timely PartD 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 clinical information needed to perform 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 as defined by the organization. Job Requirements Experience Minimum of 1 year of experience in a health plan, Pharmacy Benefit Manager (PBM), or managed care pharmacy setting. Preferred: Demonstrated experience applying clinical decision‑making in a regulated, compliance‑driven health care environment (enterprise‑scale preferred). Exposure to Medicare Part D operations, formulary management, or utilization management strongly expected. Education Bachelor’s degree in Pharmacy or a related health science field (required). Doctor of Pharmacy (PharmD), Master’s degree, or PhD in Pharmacy preferred. Equivalent combination of relevant education and demonstrated clinical experience will also be considered. Licensure Active and unrestricted Pharmacist license in the applicable state(s) (required). Skills & Competencies PartD 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. Schedule & Physical Demands Standard work schedule: Monday through Friday, 8AM–5PMPST, with availability for rotational weekend shifts as needed. Physical demands: Regularly required to talk or hear; stand, walk, sit, use hand and finger, handle or feel objects, tools, or controls; reach with hands and arms; frequently lift and/or move up to 10pounds. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions. Pay Range $113,332.00–$169,999.00 (pay range may be based on market location, education, responsibilities, experience, etc.) Equal Opportunity/Affirmative Action Statement 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. #J-18808-Ljbffr E2E Alignment Healthcare USA, LLC