Remote Clinical Pharmacist II

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 II provides operational and clinical support for the evaluation, implementation, and maintenance of Medicare Part D programs. This role is responsible for ensuring compliance with CMS regulations across key areas, including but not limited to formulary management, pharmacy network oversight, member-facing communications, provider education, pharmacy quality programs, and audit readiness. The Clinical Pharmacist II oversees PBM-delegated pharmacy services and operations, ensuring alignment with contractual, regulatory, and performance expectations. In addition, the Clinical Pharmacist II provides guidance and education to internal stakeholders and collaborates cross-functionally to support enterprise operation and member experience. The Clinical Pharmacist II supports additional managed care initiatives and clinical programs as assigned.

Job Responsibilities:

• Manage Part D Coverage Determinations, Appeals, and Grievances: Support and render Part D coverage determinations, appeals, and grievances by applying clinical expertise, plan benefits, and CMS regulatory requirements. Serve as an escalation point for complex cases, ensuring decisions are timely, well-documented, and audit ready while maintaining member access and quality of care.
• Lead Targeted Provider and Member Outreach: Conduct purposeful, clinical outreach to prescribers, pharmacies, and members to support the clinical programs and medication utilization. Support Part D and Pharmacy program initiatives to support expansion and Part D financials.
• Deliver Medication Therapy Management Services and Quality Initiatives: Perform comprehensive and targeted medication reviews for MTM-enrolled members, identifying drug therapy problems and collaborating on actionable medication plans that improve safety and adherence. Actively participate in pharmacy quality programs including Care for Older Adults Medication Review (COA-MDR) and adherence-related Stars activities that directly impact the plan's quality performance.
• Manage Benefit Build and Member-Facing Materials: Assist with annual pharmacy benefit build activities to ensure formulary and benefit accuracy. Review member-facing materials (e.g., formularies, transition notices, benefit documents) for clinical and regulatory compliance.
• Oversee PBM delegated operations and Regulatory requirements: Provide oversight of PBM-delegated pharmacy operations to ensure compliance with contractual and CMS requirements. Monitor performance, conduct audits, and collaborate with PBM partners to improve quality and access. Support and lead CMS audits and validate pharmacy-related submissions in coordination with compliance stakeholders.
• Other clinical programs and projects not listed above

Job Requirements:

Experience:

• Required: Minimum of 3 years of pharmacy experience at a health plan, Pharmacy Benefit Manager (PBM), or managed care organization.
• Preferred: Demonstrated, hands-on experience with Medicare Part D coverage determinations and appeals within an enterprise-scale or highly regulated healthcare environment. Demonstrated experience conducting MTM or equivalent clinical pharmacy programs with documented member outcomes. Prior exposure to cross-functional collaboration with teams such as Clinical Operations, Products, Provider Relations, or Compliance is expected at this level.

Education:

• Required: Bachelor's degree in Pharmacy or a related health science discipline.
• Preferred: Doctor of Pharmacy (PharmD), Master's degree, or PhD in Pharmacy. A demonstrated track record of clinical expertise and increasing responsibility may substitute for advanced degree requirements on a case-by-case basis.

Licensure:

• Required: Active and unrestricted Pharmacist license in the applicable state(s)

Specialized Skills:

• Medicare Part D Regulatory Expertise (Advanced): Deep working knowledge of CMS coverage determination and appeals processes, CDAG timelines, formulary exception standards, and applicable regulatory obligations.
• Clinical Judgment and Guideline Interpretation (Advanced): Ability to independently evaluate complex, multi-layered clinical cases against evidence-based guidelines and formulary criteria to reach sound, defensible decisions.
• Medication Therapy Management and Chronic Disease Management (Advanced): Proficiency in comprehensive and targeted medication review delivery, pharmacotherapy optimization, and documentation in MTM platforms for a Medicare-aged population.
• Pharmacy Utilization Analytics (Intermediate-Advanced): Ability to identify trends, patterns, and outliers in pharmacy utilization data; translate findings into actionable recommendations for quality improvement or clinical intervention.
• Pharmacy Benefit Management Systems and Formulary Configuration (Intermediate-Advanced): Working knowledge of PBM adjudication platforms, benefit testing processes, and formulary management tools.
• Regulatory Compliance and Audit Preparedness (Intermediate): Familiarity with Medicare Advantage compliance frameworks, HIPAA requirements, CMS audit processes, and documentation standards for coverage decisions.
• Cross-Functional Communication and Documentation (Intermediate-Advanced): Ability to produce clear, accurate clinical correspondence, case documentation, and internal guidance for diverse stakeholders including compliance officers, medical directors, and provider relations teams.

Preferred Qualifications

• Direct, hands-on experience with formulary management, benefit configuration, or pharmacy benefit testing within a Medicare Advantage plan.
• Prior experience supporting CMS regulatory audits, including CDAG audits, PDE reconciliation, or CMS readiness reviews.
• Board Certified Pharmacotherapy Specialist (BCPS) or other Board of Pharmacy Specialties (BPS) credential.
• Familiarity with Medicare Star Ratings drivers, HEDIS measures, and pharmacy-sensitive quality metrics.
• Experience with utilization management platforms or data analytics tools used in pharmacy trend analysis.
• Bilingual (English/Spanish) — particularly valuable in supporting a diverse, Medicare Advantage member population.
• CMM (Comprehensive Medication Management) training or formal MTM program certification.

Other:

• Standard work schedule: Monday through Friday, 8 AM – 5 PM PST, with availability for rotational weekend shifts as needed.
• Occasional onsite travel to the corporate office in Orange, CA may be required. Candidates should be prepared to travel up to 10% of the time to meet business needs

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: $130,332.00 - $195,498.00

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.

Originally posted on Himalayas