Clinical Pharmacist

Clever Care Health Plan; Huntington Beach (CA); Hybrid; USD 130,000 - 160,000; Full time

Job summary

Clever Care Health Plan seeks a Clinical Pharmacist to join a hybrid team serving Medicare Advantage members in Southern California. You will review Part D coverage determinations, support MTM, and collaborate with PBM partners to ensure safe, effective medication use.

The role emphasizes culturally attuned care, CMS-compliant workflows, and ongoing process improvements. A California Pharmacist license and Doctor of Pharmacy degree are required, with strong communication and cross-team

Qualifications

• Doctor of Pharmacy degree from an accredited program.
• Active California pharmacist license in good standing.
• Ability to review medication-related issues, apply defined criteria, document clearly, and escalate when needed.
• Strong written and verbal communication skills with the ability to explain pharmacy issues clearly.
• Ability to work across teams, follow through on issues, and support practical workflow improvements.
• Willingness to learn new systems, use reports, and identify trends.

Responsibilities

• Medicare pharmacy case review and documentation.
• Support MTM, care management, and interdisciplinary discussions as needed.
• Formulary, prior authorization, and exception criteria CMS-aligned readiness support.
• Part B drug review support, including Coverage Determinations and Grievances workflows.
• Monitor PBM-delegated work and resolve claims access issues; escalate between teams as needed.
• Assist with CMS audit readiness and maintain day-to-day compliance.

Skills

Clinical Judgment

Communication

Collaboration & Ownership

Systems & Data Comfort

Education

Doctor of Pharmacy degree

California pharmacist license

Job description

This position operates on a hybrid work schedule. Candidate must reside in Los Angeles or Orange County.Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California’s fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.Who Are We? Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members’ culture and values.Why Join Us?We’re on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you’ll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.Job SummaryThe Clinical Pharmacist helps build and run a reliable, member-centered pharmacy function for a Medicare Advantage Prescription Drug plan. This role combines clinical pharmacy judgment, Medicare Part D operational knowledge, formulary support, quality improvement, and close collaboration with internal teams and PBM partners.As part of Clever Care’s mission, this pharmacist will help advance culturally attuned pharmacy care by ensuring medication support, workflows, and member interactions reflect language, culture, trust, and real-life member experience. We are looking for someone who can move comfortably between clinical review, compliance requirements, daily operations, and process improvement, and who is energized by using technology in practical ways to make pharmacy workflows easier for members, providers, and staff.Core Responsibilities· Medicare pharmacy case review: Review Part D coverage determinations, formulary exceptions, redeterminations, and related cases using clinical judgment, benefit rules, CMS guidance, and clear documentation.· Medication therapy and MTM support: Review medications for safety, dosing, effectiveness, adherence opportunity, formulary alignment, and member-specific needs; support MTM, care management, and interdisciplinary care discussions as needed.· Formulary, UM, and AEP readiness: Help keep formulary, prior authorization, and exception criteria clinically sound, operationally usable, CMS-aligned, and ready for annual enrollment period changes.· Part B drug and CDAG support: Support Part B drug-related reviews and Coverage Determinations, Appeals, and Grievances workflows, including case review, documentation, escalation, and follow-up with compliance and operations.· PBM oversight and issue resolution: Help monitor PBM-delegated work, track vendor performance, resolve pharmacy claims rejects and access issues, and make sure escalations do not get lost between teams.· Compliance and audit readiness: Support CMS audit universes, source documentation, monitoring, corrective actions, and day-to-day compliance follow-through so we are ready before an audit, not scrambling during one.· Medication adherence and Stars: Support adherence, high-risk medication, and other pharmacy-related quality initiatives through outreach workflows, performance tracking, trend review, and practical process fixes.· Technician oversight: Provide day-to-day coaching, training, quality review, and practical direction for pharmacy technicians supporting clinical pharmacy operations and member-facing workflows.· Reporting, trends, and workflow improvement: Use case data, dashboards, reports, and team feedback to identify problems early, improve handoffs, simplify workflows, and give leadership useful visibility.· Culturally attuned member experience: Help our CMIO and Clinical Team build pharmacy processes that work in real life for our members, including language needs, cultural preferences, trust barriers, and how members actually use medications.Required Qualifications· Education: Doctor of Pharmacy degree from an accredited pharmacy program.· Licensure: Active California pharmacist license in good standing· Clinical Judgment: Ability to review medication-related issues, apply defined criteria, document clearly, and escalate when needed.· Communication: Strong written and verbal communication skills with the ability to explain pharmacy issues clearly.· Collaboration & Ownership: Ability to work across teams, follow through on issues, and support practical workflow improvements.· Systems & Data Comfort: Willingness to learn new systems, use reports, and identify trends.Wage Range: $130,000 to $160,000 per yearPreferred Qualifications· Managed Care or Health Plan Experience: Experience in managed care, Medicare Advantage, MAPD, PBM, health plan pharmacy, formulary management, utilization management, MTM, Coverage Determinations, Appeals, and Grievances (CDAG), Part B drug review support, Star Ratings, CMS audit support, or a managed care residency/fellowship.· Language Skills: Bilingual ability in Spanish, Korean, Vietnamese, or Mandarin.· Technology Interest: Interest in using systems, data, dashboards, and workflow tools to improve pharmacy operations and member experience.Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.#LI-Hybrid