Pharmacy Part D Auditor

Clever Care Health Plan•Huntington Beach, CA

1d•Hybrid

About The Position

Clever Care is a rapidly growing Medicare Advantage plan dedicated to serving diverse communities with innovative benefit plans that blend Western medicine with holistic Eastern practices. We are seeking a Pharmacy Part D Oversight Auditor to join our team. This role is crucial for ensuring compliance with Part D regulations, including coverage determinations, exceptions, redeterminations, and MTM program elements. The auditor will also monitor delegated PBM controls and ensure all processes are documented and audit-ready, contributing to our mission of making healthcare accessible.

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
Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking)
Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs.
Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly.
A background check is required.

Nice To Haves

PharmD or Registered Pharmacist (RPh) preferred
SNP experience strongly preferred
Must be able to travel when needed or required

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.