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.