Remote Pharmacy Programs Specialist — Part D & CMS

Clover Health; United States; Hybrid; USD 54,000 - 70,000; Full time

Benefits offered by this job

Remote-first culture

Competitive salary

401k matching

Performance bonus

Paid parental leave

ESPP

Job summary

Clover Health in the United States seeks a Pharmacy Programs Specialist to support Medicare Part D quality metrics, medication management initiatives, and CMS compliance standards.

You will validate claim adjudication to ensure access to care, perform telephonic outreach to plan members, prescribers, and pharmacies, and document activity in electronic medical records while collaborating with clinical pharmacists and cross‑functional teams.

Qualifications

• Active National Certification (CPhT) preferred.
• Minimum three years of pharmacy, managed care, medical office, or hospital experience.

Responsibilities

• Validate claim adjudication to ensure access to care.
• Provide telephonic outreach to plan members, providers, and pharmacies.
• Collaborate with Clinical Pharmacists and cross‑functional teams on medication management initiatives.
• Prepare and present data trends to support CMS quality metrics.

Skills

CPhT Certification

Pharmacy experience

Bilingual English/Spanish

CMS/Medicare knowledge

Windows PC skills

Job description

At Clover Health, we are committed to providing high-quality, affordable, and easy-to-understand healthcare plans for America’s seniors. We prioritize preventive care while leveraging data and technology through the Clover Assistant, a powerful tool that helps physicians make informed health recommendations. By giving doctors a holistic view of each member’s complete health history, we ensure better care at a lower cost—delivering the highest value to those who need it most.

The Clinical Pharmacy team is an innovative team that utilizes a member-centric approach to provide comprehensive medication management services. The Pharmacy Programs Specialist will work to support Medicare quality metrics, medication management initiatives, and maintain Centers for Medicare and Medicaid Services compliance standards.

In this role, you would perform validation of claim adjudication ensuring appropriate access to care and support telephonic outreach for plan members, providers and other healthcare professionals. In addition, document activity and maintain electronic medical records while providing the highest quality healthcare and service to plan members and other internal and external partners.

As a Pharmacy Programs Specialist you will:

• Create, manage, and respond to cases and/or escalate to Clinical Pharmacists on the Team.
• Contribute to improving Part D Star measures by resolving root causes of medication management problems and taking appropriate action to provide recommendations based on profile review or patient interview.
• Represent for the Pharmacy team and participate in cross-functional team meetings
• Collect and present data and trends from Pharmacy Benefits Manager (PBM) delegated functions to cross-functional operational workgroups to propose process improvements
• Deliver on cross-functional team initiatives and ad-hoc projects that impact Clover business goals
• Provide guidance to internal and external teams in regards to pharmacy clinical and regulatory workflows, policies and processes
• Serve as a liaison between PBM Account Management Team and Clover Health and escalate any questions that need PBM involvement for resolution.
• Organize pharmacy team meetings with internal and external partners.
• Think critically and problem solve to prioritize and work more efficiently
• Improve team’s capacity and knowledge
• Distribute work to peers and strategize completion of quality assurance projects that require short turn around times
• Provide recommendations on and deliver Part D content knowledge updates on internal knowledge base directory annually and ad-hoc
• Lead educational training for cross functional teams on Part D knowledge and vendor platforms
• Participate in call center quality assurance reviews
• Perform strategic work to increase MTMP Star measure
• Navigate and use tools and platforms required for task/queue-based work
• Show curiosity as to how work impacts the business and how that work is generated
• Complete a larger volume of assigned tasks with increasing focus on program/project-based opportunities and work and serve as a resource to others
• Communicate with the pharmacy leadership team in a timely manner when issues arise.
• File, review, and validate reports to ensure compliance with Medicare guidelines.
• Gather data and generate reports to improve clinical pharmacy quality metrics.
• Participate in training and orientation of new team members, as needed.
• Execute other job duties as assigned.

Success in this role looks like:

• Within 90 days: You have seamlessly integrated into the Pharmacy team and completed all the necessary training modules, familiarize yourself with the organization's platforms, and established a strong knowledge of Clover Health Part D benefit. You are capable of validating claim adjudication to ensure appropriate access to care and provide telephone support to plan members, prescribers, and pharmacies.
• Within 6 months: You will be fully engaged in oversight of accurate Part D benefits that are in compliance with CMS requirements. You have demonstrated the ability to collaborate effectively with interdisciplinary teams, providing member experience support and contributing to resolving member medication related escalations.
• Long-term: You will be measured based on pharmacy operational metrics, the integration of innovative technologies to enhance pharmacy services and improve patient outcomes, the enhancement of operational efficiency, and contributions to achieving the organization’s strategic objectives and key results.

You should get in touch if:

• You have a National Certification (CPhT) Pharmacy Technician License (preferred).
• You have at least three (3) years of experience working in pharmacy, managed care organization, medical office or in a hospital setting.
• You are fluent in English and Spanish, both orally and in writing.
• You have an understanding of managed care.
• You have PC skills in Windows-based applications.
• You have excellent written and oral communication skills.
• You are able to work Eastern Time (ET) hours; candidates in this time zone, preferred.

Benefits Overview:

• Financial Well-Being: Our commitment to attracting and retaining top talent begins with a competitive base salary and equity opportunities. Additionally, we offer a performance-based bonus program, 401k matching, and regular compensation reviews to recognize and reward exceptional contributions.
• Physical Well-Being: We prioritize the health and well-being of our employees and their families by providing comprehensive medical, dental, and vision coverage. Your health matters to us, and we invest in ensuring you have access to quality healthcare.
• Mental Well-Being: We understand the importance of mental health in fostering productivity and maintaining work-life balance. To support this, we offer initiatives such as No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy. Additionally, we embrace a remote-first culture that supports collaboration and flexibility, allowing our team members to thrive from any location.
• Professional Development: Developing internal talent is a priority for Clover. We offer learning programs, mentorship, professional development funding, and regular performance feedback and reviews.
• Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities
• Reimbursement for office setup expenses
• Monthly cell phone & internet stipend
• Remote-first culture, enabling collaboration with global teams
• Paid parental leave for all new parents
• And much more!

About Clover:We are reinventing health insurance by combining the power of data with human empathy to keep our members healthier. We believe the healthcare system is broken, so we've created custom software and analytics to empower our clinical staff to intervene and provide personalized care to the people who need it most.

We always put our members first, and our success as a team is measured by the quality of life of the people we serve. Those who work at Clover are passionate and mission-driven individuals with diverse areas of expertise, working together to solve the most complicated problem in the world: healthcare.

From Clover’s inception, Diversity & Inclusion have always been key to our success. We are an Equal Opportunity Employer and our employees are people with different strengths, experiences, perspectives, opinions, and backgrounds, who share a passion for improving people's lives. Diversity not only includes race and gender identity, but also age, disability status, veteran status, sexual orientation, religion and many other parts of one’s identity. All of our employee’s points of view are key to our success, and inclusion is everyone's responsibility.

#LI-REMOTE

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. We are an E-Verify company.

Final pay is based on several factors including but not limited to internal equity, market data, and the applicant’s education, work experience, certifications, etc.

A reasonable estimate of the base salary range for this role is:

$53,800 - $70,000 USD

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