The Clinical Pharmacist Reviewer performs independent clinical and policy reviews of Medicare Part D reconsideration appeals to determine coverage eligibility. They also analyze pharmacy claims and clinical documentation to ensure compliance with CMS regulations and contractual requirements.
This position is contingent upon the successful award of the associated contract. Employment is not guaranteed until the contract is awarded, and the position is officially activated. Job responsibilities and requirements are subject to change.
About J29 J29 is an employee centered healthcare management consulting company that specializes in processing, reviewing, and analyzing medical claims, records, disputes, and audits. Established in 2017, J29 prides itself on its employee centric culture and high employee retention rates that allow us to ensure that we are creating a working environment that prioritizes the employee experience. Our team brings corporate performance that stretches to various areas where we can provide our clinical, healthcare policy, and compliance expertise through our support to health and human service programs at the State, Federal, and Commercial levels.
Overview J29 is seeking an experienced Clinical Pharmacist Reviewer to support the contract through the independent clinical review of Medicare Part D reconsideration appeals and program integrity-related activities. The Clinical Pharmacist Reviewer applies advanced clinical knowledge, Medicare Part D regulations, CMS guidance, and pharmacy benefit expertise to evaluate appeal cases, assess coverage eligibility, and support accurate and defensible determination recommendations.
Working within a multidisciplinary review environment, the Clinical Pharmacist Reviewer analyzes clinical and pharmacy documentation, evaluates complex drug coverage issues, and ensures compliance with applicable regulatory and contractual requirements. The ideal candidate possesses deep knowledge of Medicare Part D operations, strong analytical skills, and the ability to independently assess cases while maintaining the highest standards of quality, consistency, and program integrity. Role & Responsibilities
Perform independent clinical and policy review of reconsideration appeals
Perform independent clinical and policy reviews of Medicare Part D reconsideration appeals.
Apply Medicare Part D statutes, regulations, CMS guidance, and contract-specific requirements in the evaluation of appeal cases.
Assess clinical documentation, pharmacy claims, and supporting records to determine coverage eligibility and payment appropriateness.
Evaluate medical necessity, formulary requirements, utilization management criteria, and benefit coverage limitations.
Analyze Prescription Drug Event (PDE) data and other relevant documentation as part of the appeal review process.
Draft clear, concise, and well-supported clinical recommendations and determination rationales.
Identify discrepancies, documentation deficiencies, or potential compliance concerns during case reviews.
Collaborate with medical reviewers, appeals analysts, and operational staff to resolve complex cases and ensure consistent adjudication.
Maintain complete and accurate documentation of review findings in accordance with program requirements.
Participate in quality assurance reviews, calibration activities, and peer review processes.
Support audit readiness efforts and respond to quality or compliance inquiries as needed.
Assist in the development and refinement of clinical review guidelines, training materials, and operational procedures.
Ensure compliance with CMS regulations, Medicare Part D requirements, HIPAA standards, and organizational policies.
Support activities that promote program integrity and the accurate administration of Medicare benefits.
Experience / Expertise
Doctor of Pharmacy (PharmD) or Bachelor of Science in Pharmacy required.
Active, unrestricted pharmacist license in good standing.
Five (5) or more years of experience supporting Medicare Part D operations, appeals, utilization management, pharmacy benefit management, healthcare compliance, audit activities, or program integrity initiatives.
Strong knowledge of Medicare Part D regulations, coverage determinations, formulary administration, appeals processes, and Prescription Drug Event (PDE) requirements.
Preferred Qualifications
Experience reviewing pharmacy claims, clinical documentation, and complex coverage determinations.
Ability to interpret CMS guidance, federal regulations, and pharmacy policies to support consistent and compliant decision-making.
Strong clinical assessment, analytical, and critical thinking skills.
Experience preparing written clinical findings, recommendations, and appeal determination rationales.
Knowledge of drug utilization review, medication safety principles, and evidence-based clinical practice.
Experience supporting CMS contractors or other healthcare oversight organizations preferred.
Strong written and verbal communication skills.
Proficiency in Microsoft Office applications and electronic case management systems.
Ability to manage multiple priorities while maintaining exceptional attention to detail and quality.
Hourly Rate: $65.00 - 68.00 hourly
J29, Inc. is committed to hiring and retaining a diverse workforce. We are proud to be an Equal Opportunity/Affirmative Action Employer, making decisions without regard to race, color, religion, creed, sex, sexual orientation, gender identity, marital status, national origin, age, veteran status, disability, or any other protected class. J29, Inc. is a proud Veteran friendly employer.
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