Pharmacy Part D Auditor
About The Position
This position operates on a hybrid work schedule. Candidate must reside in Los Angeles or Orange County. Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California’s fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth. Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members’ culture and values. We’re on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you’ll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation. The Pharmacy Part D Oversight Auditor owns independent auditing and monitoring of Part D clinical compliance: CDAG (coverage determinations, exceptions, redeterminations), MTM program elements (targeting, CMR/TMR), and delegated PBM controls; ensures timeliness, accuracy, and member impact remediation are documented and audit-ready.
Requirements
- Bachelor of Science in Pharmacy
- 3–5+ years Part D operations/compliance auditing.
- Proficiency with 42 C.F.R. Part 423 Subparts D & M and current MTM expectations
- Deep knowledge of: CMS Program Audit (CDAG, FA, CPE)
- Deep knowledge of: Delegation oversight principles and evidence requirements
- Deep knowledge of: Part D regulatory structure and operational requirements
Nice To Haves
- PharmD or Registered Pharmacist (RPh) preferred
- SNP experience strongly preferred
Responsibilities
- Audit coverage determinations and redeterminations timeliness, notice content, exceptions processing, and effectuation under Part 423 Subpart M.
- Validate MTM targeting criteria, Comprehensive and Targeted Medication Review (CMR/TMR) completion, and annual CMS submission/attestation compliance under §423.153 and current year guidance.
- Monitor delegated PBM and pharmacy FDRs for adherence to plan policy and CMS requirements; track corrective actions consistent with delegation oversight duties.
- Coordinate with UM/Part C on benefit coordination issues (e.g., B vs D drug coverage boundaries) affecting member access and appeals.
- Prepare CDAG/MTM dashboards and Board-level reporting
Benefits
- Background check is required.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
