Clinical Pharmacist I - Remote
Core
Reviewing coverage determinations and appeals for Medicare Part D and Part C plans, and conducting Medication Therapy Management (MTM) reviews for high-risk senior members.
Role type
Clinical Pharmacist I (Managed Care)
Builds
Compliant coverage decisions and optimized medication regimens for Alignment Health Plan members
Domain
US Healthcare / Medicare Part D / Medication Therapy Management
Deliverable
client delivery
Required skills
Part D regulatory knowledge, Medication Therapy Management (MTM), Clinical decision-making, Pharmacy Benefit Management systems, Healthcare regulatory compliance, Medical documentation
Preferred skills
CDAG experience, MTM platform experience, Bilingual (English/Spanish)
Technologies
PBM adjudication platforms, pharmacy management software, claims-related systems
Responsibilities
Review and render Part D coverage determination and appeal requests; Conduct comprehensive medication reviews via telephone for MTM program members; Participate in pharmacy quality improvement projects aligned with Medicare Star Ratings; Maintain records of clinical reviews and coverage determinations
Seniority
Entry-level to Mid-level, hands-on IC