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

• 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

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

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.

•

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.

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 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 . Originally posted on Himalayas