Hybrid Pharmacy Part D Compliance Auditor

Clever Care Health Plan; Huntington Beach (CA); Hybrid; USD 80,000 - 90,000; Full time

Job summary

Clever Care Health Plan in Southern California is seeking a Pharmacy Part D Oversight Auditor to lead independent auditing of Part D clinical compliance, MTM elements, and delegated PBM controls, ensuring timely, accurate, audit-ready documentation.

You will coordinate with UM/Part C on benefit coordination, prepare dashboards, and deliver Board-level reporting while adhering to CMS requirements. Requires PharmD or RPh preferred, BS in Pharmacy, and 3–5+ years of Part D auditing.

Qualifications

• 3–5+ years Part D operations/compliance auditing.
• Proficiency with 42 C.F.R. Part 423 Subparts D & M.
• Strong knowledge of MTM (CMR/TMR) and CMS guidance.

Responsibilities

• Audit coverage determinations and redeterminations timeliness, notice content, exceptions processing, and effectuation under Part 423 Subpart M.
• Validate MTM targeting criteria, 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.
• Coordinate with UM/Part C on benefit coordination issues affecting member access and appeals.
• Prepare CDAG/MTM dashboards and Board-level reporting.

Skills

Part D auditing

CMS audits

Delegation oversight

Regulatory compliance

Education

Bachelor of Science in Pharmacy

PharmD or RPh preferred

Job description

Clever Care Health Plan in Southern California is seeking a Pharmacy Part D Oversight Auditor to lead independent auditing of Part D clinical compliance, MTM elements, and delegated PBM controls, ensuring timely, accurate, audit-ready documentation.

You will coordinate with UM/Part C on benefit coordination, prepare dashboards, and deliver Board-level reporting while adhering to CMS requirements. Requires PharmD or RPh preferred, BS in Pharmacy, and 3–5+ years of Part D auditing.