Clinical Pharmacist, Coverage Determination

Viva-Health; Birmingham (AL); On-site; USD 110,000 - 140,000; Full time

Benefits offered by this job

Comprehensive Health Coverage

401(k) Savings Plan with company match

Paid Time Off

9 Holidays + Floating Holiday

Tuition Assistance

Flexible Spending Accounts

Life Insurance and Disability Coverage

Employee Wellness Program

Training and Development Programs

Job summary

Viva Health, based in Birmingham, AL, seeks a Clinical Pharmacist for Coverage Determination to provide leadership on clinical pharmacy decisions and programs. You will serve as a clinical reviewer for Medicare Part D and Commercial lines, guiding determinations and ensuring alignment with CMS policies.

Join Viva Health, a Premier health plan with strong ties to UAB Health System, offering comprehensive benefits, PTO, tuition assistance, retirement plans, and development programs while

Qualifications

• Registered Pharmacist (Rph) or Doctor of Pharmacy (PharmD).
• Licensed Pharmacist in good standing with the State of Alabama.
• Excellent oral and written communication skills.
• Good computer skills including Microsoft suite of products.

Responsibilities

• Lead Coverage Determination reviews for Medicare and Commercial lines per applicable policies and regulations.
• Research individual cases and render decisions with Pharmacy department leaders or Medical Director input.
• Assist in maintaining criteria for coverage determinations, exception requests, complaints, and appeals, and ensure criteria and decisions are properly communicated and applied.
• Assist department management in developing and maintaining coverage determination decision trees.
• Ensure processes are carried out in accordance with CMS and other regulatory requirements.

Skills

Communication skills

Microsoft Office

Oral and written communication

Clinical pharmacy knowledge

Job description

Clinical Pharmacist, Coverage Determination

Job Category: Pharmacy

Requisition Number: CLINI003092

• Posted : September 17, 2026
• Full-Time

Locations

Showing 1 location

Bham-Corporate Office
Birmingham, AL 35203, USA

Description

Clinical Pharmacist, Coverage Determination

Location: Birmingham, AL

Job Description

The Coverage Determination Pharmacist will provide leadership at the health plan regarding clinical pharmacy decisions and programs. This position will serve as a clinical reviewer for the Plan’s Commercial (employer groups) and Medicare Part D Coverage Determinations.

Why VIVA HEALTH?

VIVA HEALTH, part of the renowned University of Alabama at Birmingham (UAB) Health System, is a health maintenance organization providing quality, accessible health care. Our employees are a part of the communities they serve and proudly partner with members on their healthcare journeys.

VIVA HEALTH has been recognized by Centers for Medicare & Medicaid Services (CMS) as a high-performing health plan and has been repeatedly ranked as one of the nation's Best Places to Work by Modern Healthcare.

• Comprehensive Health, Vision, and Dental Coverage
• 401(k) Savings Plan with company match and immediate vesting
• Paid Time Off (PTO)
• 9 Paid Holidays annually plus a Floating Holiday to use as you choose
• Tuition Assistance
• Flexible Spending Accounts
• Community Service Time Off
• Life Insurance and Disability Coverage
• Employee Wellness Program
• Training and Development Programs to develop new skills and reach career goals
• Perform Coverage Determination reviews (prior authorizations, formulary exceptions, etc.) for both Medicare and Commercial lines of business. Reviews will be completed in accordance with applicable policies and procedures, regulations, and guidelines.
• Research individual cases and render decisions with Pharmacy department leaders or Medical Director input as needed.
• Assist in maintaining criteria for pharmacy related coverage determinations, exception requests, complaints, and appeals, and ensure criteria and decisions are properly communicated and applied.
• Assist department management in the development and maintenance of coverage determination decision trees.
• Assist in ensuring processes are carried out in accordance with Centers for Medicare & Medicaid Services (CMS) and other regulatory requirements.

REQUIRED QUALIFICATIONS:

• Registered Pharmacist (Rph) or Doctor of Pharmacy (PharmD)
• Licensed Pharmacist in good standing with the State of Alabama
• Excellent oral and written communication skills
• Good computer skills including Microsoft suite of products

PREFERRED QUALIFICATIONS:

• 5 years’ experience in Medicare Advantage Coverage Determinations, health plan, or pharmacy benefits management

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.