Clinical Pharmacist- Medicare Appeals (Hybrid: PA, NJ, DE Only)
Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together we will achieve our mission to enhance the health and well-being of the people and communities we serve.
The Clinical Pharmacist is responsible for performing the clinical components of the pharmacy benefit, with a focus on Medicare pharmacy programs, Large Group Medicare operations, formulary administration, regulatory compliance, and clinical review and consultation in support of coverage determinations, appeals, and grievances. This position reviews clinical information, healthcare utilization, and medication history; applies clinical judgment, Medicare Part D regulations, pharmacy policy, and evidence-based criteria to support coverage decisions; and serves as a clinical resource to physicians, prescribers, Medical Directors, interdisciplinary teams, and operational partners. The Clinical Pharmacist also supports member and provider inquiries, improves healthcare outcomes, ensures patient safety, promotes cost-effective medication use, maintains regulatory compliance, and coordinates care efficiently and effectively.
Responsibilities:
- Serve as a clinical pharmacy subject matter expert supporting Medicare pharmacy programs, coverage and utilization management processes, formulary administration, and regulatory compliance.
- Review clinical information, utilization, medication history, and documentation; apply regulations, policy, and evidence-based criteria to provide clinically appropriate recommendations.
- Collaborate with prescribers, Medical Directors, interdisciplinary teams, and operational partners to address inquiries and support timely case resolution.
- Identify trends, risks, and process improvements, and communicate recommendations to leadership and key stakeholders.
- Serve as a pharmacy liaison by providing clinical consultation, education, job aids, and training to cross-functional teams.
- Ensure compliance with CMS requirements, internal policies, and applicable quality standards, including support for audits, reporting, and regulatory submissions.
Required Qualifications:
- Doctor of Pharmacy (PharmD) or Bachelor of Science in Pharmacy with 5+ years of relevant clinical pharmacy experience.
- Active, unrestricted pharmacist license.
- 5 or more years of relevant clinical pharmacy experience in managed care or a related setting or completion of an accredited AMCP Managed Care Residency.
- Working knowledge of Medicare Part D benefits, formulary administration, compliance, and coverage, appeal, and grievance processes.
- Ability to evaluate clinical information, apply evidence-based criteria and policy, and collaborate with clinical and cross-functional teams to support appropriate treatment, optimize health outcomes, and resolve complex clinical issues.
- Strong analytical, problem-solving, organizational, and communication skills.
- Ability to work independently and within a team setting to achieve goals and meet deadlines.
- Proficiency in Microsoft Word, Excel, and Outlook.
Preferred Qualifications:
- Experience supporting Medicare Advantage or Part D coverage reviews, appeals, utilization management, and formulary administration.
- Knowledge of CMS, NCQA, and PQA standards.
- Proficiency in Microsoft Word, Excel, and Outlook.
- Current knowledge and expertise in clinical pharmacology, disease management, and managed care pharmacy.
- Experience with team-based care and interdisciplinary collaboration.
IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.
Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.
Inclusion and Belonging
At IBX, everyone can feel valued, supported, and comfortable to be themselves, and all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. Celebrating and embracing diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.
About Our Company
Serving more than 8 million people nationwide, including 2.5 million in southeastern Pennsylvania, Independence Health Group — together with its subsidiaries — is the leading health insurance organization in the Philadelphia region. Our mission to build healthier lives for you, your family, and your employees shapes our actions and decisions every day.
At Independence, we see each of our members as an individual, with unique needs and concerns. We’re dedicated to harnessing the very latest ideas and technologies to deliver access to care that meets those needs and surpasses your expectations. For more information about Independence access our website at www.ibx.com. We’re revolutionizing health care, and our focus is on you!
Equal Employment Opportunity
IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.
Agency Disclaimer
All resumes submitted directly to an Independence Blue Cross employee from a vendor via email, the Internet or in any other form without a valid written search agreement in place for this position from the Independence Blue Cross Family of Companies Human Resources Department will be deemed the sole property of Independence Blue Cross and the Independence Blue Cross Family of Companies. Please note that no fee will be paid in the event the candidate is hired by Independence Blue Cross or the Independence Blue Cross Family of Companies as a result of the referral or through means other than our established process.