Clinical Pharmacist I – Medicare Part D, Prior Auth

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🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $113.3k - $170k / year

⏰ Full Time

🟢 Junior

💊 Pharmacist

👻 Ghost score 0%

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Alignment Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 2013

⚕️ Healthcare Insurance

🛡️ Insurance

🏥 Healthcare

💰 $135M Series C on 2020-03

Healthcare Insurance • Insurance • Healthcare

Alignment Health is dedicated to providing comprehensive care for Medicare members, emphasizing the needs of seniors, the chronically ill, and those who are frail. With a mission to transform senior healthcare, Alignment Health leverages a tailored care model and advanced technology to deliver high-quality, low-cost healthcare services. Their 24/7 concierge care team collaborates with trusted local providers to ensure that every member receives personalized care, reflecting the company's commitment to treating all members as valued family members.

📋 Description

• Review and render Part D coverage determination and appeal requests • Apply clinical judgment, plan benefits, and CMS requirements to render compliant decisions • Collaborate with medical directors by providing clinical information for reviews • Conduct comprehensive medication reviews and targeted interventions for MTM members • Identify drug therapy problems, optimize regimens, and develop medication action plans • Perform Care for Older Adults Medication Reviews to support Stars quality measures • Participate in pharmacy quality improvement projects aligned with Medicare Star Ratings, HEDIS measures, and internal clinical standards • Identify gaps in care and contribute clinical expertise to improve safety metrics, adherence rates, and plan performance • Maintain records of clinical reviews, coverage determinations, and consultations in accordance with CMS timelines and organizational standards • Support additional managed care functions and other assigned duties and projects

🎯 Requirements

• Minimum one year of experience working at a health plan, Pharmacy Benefit Manager (PBM), or in a managed care pharmacy setting • Bachelor's degree in Pharmacy or a related health science field • Active and unrestricted pharmacist license in at least one U.S. state • In-depth understanding of CMS Medicare Part D coverage determination and appeal processes, CDAG timelines, and formulary exception criteria • Proficiency in conducting CMR and TMR reviews • Ability to evaluate clinical literature, formulary criteria, and prescribing guidelines • Experience navigating PBM adjudication platforms, pharmacy management software, and claims-related systems • Working knowledge of CMS regulations, HIPAA, and Medicare Advantage plan compliance requirements • Ability to comprehend, interpret, and produce pharmacy-related reports, clinical correspondence, and coverage decision letters • Competence with mathematical calculations, statistical interpretation, and using data to support quality and operational decision-making • Availability for rotational weekend shifts as needed • Bilingual English/Spanish is an asset

🏖️ Benefits

• Fully remote work • Monday–Friday schedule • Opportunity for growth and innovation • Reasonable accommodations for individuals with disabilities • Equal Opportunity/Affirmative Action employment