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Posted: 10/18/2026Clinical Pharmacist I – Medicare Part D, Prior Auth
Alignment HealthCore Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Medicare Part D coverage determination and appeals, with a strong ability to conduct comprehensive medication reviews and optimize drug therapy regimens. Proficient in navigating pharmacy management software and ensuring compliance with CMS regulations and quality measures.
Highest-signal resume keywords
Medicare Part D Coverage DeterminationComprehensive Medication ReviewsPharmacy Management SoftwareActive Pharmacist LicenseCMS Regulations Compliance
About the role
Key responsibilities & impact- 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
What you’ll need- 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
Comp & perks- Fully remote work
- Monday–Friday schedule
- Opportunity for growth and innovation
- Reasonable accommodations for individuals with disabilities
- Equal Opportunity/Affirmative Action employment
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical JudgmentMedication Action PlansDrug Therapy Problem IdentificationStatistical InterpretationMathematical CalculationsClinical Literature EvaluationFormulary Criteria UnderstandingPharmacy-Related Report ProductionCoverage Decision LettersPBM Adjudication Platforms
Soft Skills
CollaborationCommunicationProblem-Solving
Tools & Technologies
Claims-Related SystemsPharmacy Management Software
Certifications & Qualifications
Active Pharmacist License
Industry Keywords
CMS RequirementsManaged Care PharmacyHEDIS MeasuresStars Quality MeasuresMedicare Advantage ComplianceHIPAAQuality Improvement Projects