Clinical Pharmacist Advisor

About the Role

The Clinical Pharmacist Advisor supports Medicare members, providers, and prescribers by reviewing pharmacy benefit requests, ensuring accurate case setup, evaluating clinical information, and supporting coverage determination processes in accordance with Medicare guidelines and regulatory requirements. This role is responsible for reviewing clinical documentation, applying professional clinical judgment, and ensuring timely, accurate processing of requests while maintaining compliance with CMS regulations, quality standards, and productivity expectations. The position requires strong analytical skills, attention to detail, and the ability to interpret clinical documentation, Medicare guidance, and technical procedures. The Clinical Pharmacist Advisor may conduct outreach to providers to obtain additional clinical information needed for case review and decision-making. Success in this role requires excellent communication skills, adaptability to evolving work instructions, proficiency with technology, and the ability to work independently in a fully remote environment while maintaining high-quality service standards.

Responsibilities

• Review and process Medicare pharmacy benefit requests and appeals
• Accurately establish and document cases in applicable systems
• Review clinical documentation and apply Medicare guidelines to support coverage determinations
• Conduct outreach to providers, prescribers, and members when additional information is required
• Interpret medical correspondence, technical procedures, and Medicare regulations
• Ensure compliance with CMS timelines, quality standards, and productivity expectations
• Utilize clinical judgment and drug compendia resources to support case reviews
• Maintain complete and accurate case documentation
• Follow departmental procedures, work instructions, and regulatory requirements
• Participate in coaching sessions, performance feedback discussions, and professional development activities
• Navigate multiple systems and applications while performing data entry tasks
• Support a positive member and provider experience through professional communication

Required Qualifications

• Bachelor's Degree in Pharmacy (B.Pharm) or Doctor of Pharmacy (Pharm.D.) from an accredited institution
• Active Registered Pharmacist license in good standing in the state of residence
• Minimum 2 years of pharmacist experience in managed care, pharmacy, or related healthcare environment
• Strong attention to detail and ability to accurately review clinical documentation
• Ability to read, analyze, and interpret medical correspondence, business documents, technical procedures, and Medicare regulations
• Strong verbal and written communication skills
• Ability to manage multiple priorities in a fast-paced, highly regulated environment
• Ability to maintain accurate documentation and meet productivity, quality, and CMS-mandated timelines
• Strong computer proficiency, including Microsoft Excel and Microsoft Word
• Ability to work independently in a productivity-driven environment
• Experience with data entry and navigating multiple systems simultaneously
• Ability to work on camera during training sessions, supervisor meetings, and team meetings
• Dedicated, quiet work-from-home environment
• Wired internet connection with minimum speeds of 25 Mbps download and 5 Mbps upload

Preferred Qualifications

• Previous experience in a Pharmacy Benefit Manager (PBM) environment
• Previous experience in managed care or Medicare operations
• Experience in institutional healthcare settings
• Knowledge of Microsoft Access, PowerPoint, and Visio
• Experience supporting Medicare Part D or Medicare appeals processes