Pharmacy Part D 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

Location & Work Schedule

This position operates on a hybrid work schedule. Candidate must reside in Los Angeles or Orange County.

About Us

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.

Who Are We? 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.

Why Join Us? 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.

Job Summary

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.

Functions & Job 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.

Qualifications

Required Qualifications

• 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)
• Delegation oversight principles and evidence requirements
• Part D regulatory structure and operational requirements.

Preferred Qualifications

• PharmD or Registered Pharmacist (RPh) preferred
• SNP experience strongly preferred.

Wage Range

$80,000 to $90,000 per year

Physical & Working Environment

Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation:

• Must be able to travel when needed or required
• 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.

Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and the public. May occasionally be required to work irregular hours based on the needs of the business.

Leadership Expectations

• Model the Way
• Clarify values by finding your voice and affirming shared values
• Set the example by aligning actions with shared values
• Inspire a Shared Vision
• Envision the future by imagining exciting and ennobling possibilities
• Enlist others in a common vision by appealing to shared aspirations
• Challenge the Process
• Search for opportunities by seizing the initiative and looking outward for innovative ways to improve
• Experiment and take risks by consistently generating small wins and learning from experience
• Enable Others to Act
• Foster collaboration by building trust and facilitating relationships
• Strengthen others by increasing self-determination and developing competence
• Encourage the Heart
• Recognize contributions by showing appreciation for individual excellence
• Celebrate the values and victories by creating a spirit of community

Equal Employment Opportunity

Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affimitive Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

Salary Disclosure

Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.