Clinical Pharmacist I - Medicare Part D / Prior Auth (Remote | M-F, 8am-5pm Pacific) at Alignment Healthcare

Job description

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together. Alignment Health is seeking a Clinical Pharmacist I to join the pharmacy Team. A Clinical Pharmacist I is a remote, full-production managed care pharmacy role supporting Medicare Part D members. The position primarily supports Part D prior authorization and coverage determination / appeal reviews, along with Medication Therapy Management (MTM) activities. The pharmacist applies clinical judgement, plan benefits, and CMS requirements to deliver timely, compliant coverage decisions and medication reviews. As a Clinical Pharmacist I, you will review 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. What You Should Know - Schedule: Monday–Friday, 8:00 AM–5:00 PM Pacific Time - Weekend Rotation: Rotational weekend coverage is required, currently approximately every 4–5 weeks, based on business needs and case volume - Location: Fully remote - Licensure: Active, unrestricted pharmacist license in at least one U.S. state required - Required Experience: Minimum one year of health plan, PBM, or managed-care pharmacy experience - Highly Preferred: Medicare Part D prior authorization, coverage determination, appeals/redetermination, or pharmacy utilization management experience - Additional Relevant Experience: Medication Therapy Management, CMR/TMR, formulary exceptions, B vs. D determinations, quantity limits, step therapy, and other Medicare Part D pharmacy operations 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 clinical information needed to perform clinical 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, cove