Remote Clinical Pharmacist — Medicare Part D & MTM

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 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