Pharmacy Part D Auditor

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.
• Cook 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

• 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
• Envision the future by imagining exciting and ennobling possibilities
• Enlist others in a common vision by appealing to shared aspirations
• 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
• 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
• Create a spirit of community