Responsible for reviewing Part D coverage determinations and appeals to ensure compliance with CMS regulations and plan benefits. Conducts Medication Therapy Management (MTM) activities and comprehensive medication reviews to improve care for high-risk senior members.
Requirements summary
Requires a Bachelor's degree in Pharmacy or related field and at least one year of experience in a health plan, PBM, or managed care pharmacy setting. Must hold an active and unrestricted Pharmacist license in the applicable state.
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.
The Clinical Pharmacist I is responsible for reviewing 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.
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 clinincal information needed to perform clinincal 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 Part D, including CMS guidelines on coverage determinations, appeals, and grievances (CDAG).
Other duties and projects not listed above Job Requirements: 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 the applicable state(s)
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
Prior experience specifically in CDAG (coverage determinations, appeals, and grievances) within a Medicare Advantage health plan environment. Previous Medication Therapy Management experience, including CMR delivery and documentation in an MTM platform Bilingual (English/Spanish) — an asset in serving diverse Medicare Advantage member populations.
Other
Standard work schedule: Monday through Friday, 8 AM – 5 PM PST, with availability for rotational weekend shifts as needed.
Essential
Physical
Functions: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 1. While performing the duties of this job, the employee is regularly required to talk or hear. 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. 2. The employee frequently lifts and/or moves up to 10 pounds. 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. *DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email careers@ahcusa.com. 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.
