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

Alignment Healthcare USA, LLC in; Orange (CA); Remote; USD 113,000 - 170,000; Full time

Job summary

Alignment Health seeks a Clinical Pharmacist I to support Medicare Part D operations in a fully remote, production-driven environment. The role focuses on Part D coverage determinations, redeterminations, and MTM activities while adhering to CMS regulations and plan benefits for Alignment Health Plan members.

Responsibilities include conducting MTM reviews, collaborating with medical directors, and supporting quality initiatives to improve adherence and outcomes for high-risk seniors within a

Qualifications

• Minimum 1 year of health plan, PBM, or managed-care pharmacy experience.
• Experience applying clinical decision-making in a regulated healthcare environment (enterprise-scale preferred).
• Experience in CDAG (coverage determinations, appeals, and grievances) within a Medicare Advantage health plan environment preferred.

Responsibilities

• Review Part D coverage determinations and appeals to ensure clinical appropriateness and CMS compliance.
• Conduct comprehensive MTM reviews via telephone to identify drug therapy problems and optimize regimens.
• Support quality initiatives aligned with Medicare Stars, HEDIS, and internal standards.
• Maintain records of clinical reviews, determinations, and consultations per CMS timelines and CMS/CDAG guidelines.
• Perform other duties and projects as assigned.

Skills

Part D regulatory & formulary

MTM services

Clinical decision-making

PBM systems

Regulatory compliance

Medical documentation

Data interpretation

Education

Bachelor's degree in Pharmacy

Doctor of Pharmacy (PharmD) or higher

Tools

PBM software

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, coverage determinations, and consultations in accordance with CMS timelines and organizational standards. Adhere to all regulatory frameworks governing Medicare PartD, including CMS guidelines on coverage determinations, appeals, and grievances (CDAG).
• Other duties and projects not listed above

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 at least one U.S. state required.

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

• Preferred: Prior experience specifically in CDAG (coverage determinations, appeals, and grievances) within a Medicare Advantage health plan environment.
• Preferred: Previous Medication Therapy Management experience, including CMR delivery and documentation in an MTM platform.
• Preferred: Bilingual (English/Spanish) - an asset in serving diverse Medicare Advantage member populations.

Standard work schedule

Monday through Friday, 8 AM-5 PM PST, with availability for rotational weekend shifts as needed.

Essential Physical Functions

1. While performing the duties of this job, the employee is regularly required to talk or hear.
2. 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.
3. The employee frequently lifts and/or moves up to 10 pounds.
4. 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.

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.

Alignment Health is championing a new path in senior care that empowers members to age well and live their most vibrant lives. Our mission-focused team makes high-quality, low-cost care a reality for members every day. Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most. We believe that great work comes from people who are inspired to be their best. We've built a team of people who want to make a difference in the lives of the seniors we serve. Come join the team that is changing health care — one person at a time.