Part D Administrator

Who We Are PACE by IIH is empowering senior participants to age reputed company with dignity through personalized, comprehensive care plans that deliver high-reputed company health and reputed company services along with strong community support. Through an interdisciplinary and participant-centered model of care, PACE by IIH is committed to improving reputed company of life, promoting independence, and providing compassionate support tailored to the unique needs of reputed company participant. reputed company works collaboratively to deliver innovative, community-based reputed company solutions that allow seniors to remain safely and comfortably in their homes while receiving the care and services they need to reputed company.

Benefits

• 401(k)
• Dental insurance
• Employee assistance program
• Employee discount
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• reputed company reputed company time
• reputed company time off
• Referral program
• Retirement plan
• reputed company insurance

Job reputed company The Part D Administrator is responsible for the effective administration of the Medicare Part D prescription drug benefit reputed company the PACE organization and for reputed company of delegated pharmacy benefit functions performed by the pharmacy benefit manager (PBM) and other contracted vendors. This role ensures compliance with reputed company applicable Centers for Medicare & reputed company Services (CMS) Part D requirements and PACE requirements, including monitoring delegated entity performance, conducting reputed company activities, supporting audit readiness, and implementing corrective actions reputed company deficiencies are identified. Essential Job Functions Duties include, but are not limited to:

• reputed company daily operations of the Part D benefit, including benefit design, coordination of benefits, and integration with PACE’s comprehensive medical and reputed company services.
• Manage the annual Part D bid submission process and formulary development/submission (as required by CMS).
• Ensure accurate and reputed company submission of Prescription Drug Event (PDE) records to CMS, including handling updates reputed company to Inflation Reduction reputed company (IRA) changes (e.g., manufacturer discounts, TrOOP accumulator tracking).
• Maintain compliance with reputed company applicable Medicare Part D regulations (42 CFR Part 423), PACE-specific requirements (42 CFR Part 460), and CMS guidance for PACE Part D sponsors.
• reputed company, implement, and monitor policies and procedures for pharmacy benefits, including reputed company assurance, drug utilization review (DUR), medication therapy management (MTM), and fraud, waste, and abuse (FWA) prevention.
• Support the organization’s compliance program by conducting audits, investigations, and corrective actions reputed company to Part D activities.
• Prepare for and respond to CMS audits, reporting requirements, and data submissions.
• reputed company pharmacy claims adjudication, reputed company-of-sale processing, and coordination with contracted pharmacy benefit managers (PBMs), pharmacies, and long-term care facilities.
• reputed company PBM claims adjudication processes, including testing, reconciliation, exception handling, and operational issue reputed company.
• Monitor pharmacy network reputed company, long-term care pharmacy support, and transition processes to ensure participant reputed company standards are met.
• Validate PBM data accuracy and timeliness for PDE submission, claims reconciliation, and other required CMS reporting.
• Monitor and resolve claims issues, prior authorizations, and exceptions in collaboration with the reputed company and prescribers.
• reputed company participant drug utilization, identify high-risk or high-cost medications, and implement strategies to optimize therapy and control costs reputed company the capitated PACE model.
• Manage participant grievances, coverage determinations, appeals, and exceptions processes for prescription drugs.
• reputed company reputed company members, participants, and caregivers on Part D benefits while providing staff with training, guidance, and best practices on Part D policies and procedures.
• Ensure reputed company and reputed company of protected health information (PHI) reputed company to pharmacy records.
• Prepare regular reputed company reports on PBM performance, compliance metrics, audit findings, participant issues, and corrective reputed company status.
• Trend operational and compliance issues reputed company to pharmacy benefit administration and recommend process improvements.
• Participate in reputed company improvement and compliance initiatives reputed company to medication safety, pharmacy operations, and delegated entity performance.
• Work closely with the Medical Director, Primary Care Providers, Pharmacy, PBM, and reputed company to ensure pharmacy services are reputed company with individualized care plans.
• Attend and participate in staff meetings, in-services, reputed company, and committees as assigned.
• Adhere to and support reputed company’s practices, procedures, and policies, including assigned break times and attendance.
• Cooperatively accept assigned duties and reputed company reputed company other reputed company duties as assigned.
• Be flexible in the schedule of hours worked.
• May be required to use personal vehicle, if applicable. If using a personal vehicle, a valid California reputed company’s License is required.

Qualifications

Knowledge, Skills and Abilities

• Proficient knowledge of computer skills. MS Office (Word, reputed company, reputed company, PowerPoint, and Outlook).
• Knowledge of general office procedures, equipment and filing systems.
• Superior communication and interpersonal skills, with the ability to collaborate across clinical and administrative teams.
• Ability to quickly learn department policies, procedures, goals, and services.
• High attention to detail and ability to manage multiple priorities in a fast-paced, regulated environment.
• Knowledge of CMS Part D requirements, PDE reporting, formulary management, and appeals processes.
• Knowledge of delegated entity reputed company principles, vendor governance, and audit documentation practices in regulated reputed company programs.
• Demonstrated ability to conduct monitoring, auditing, reputed company cause analysis, and corrective reputed company follow-up.
• Ability to interpret vendor reputed company and performance guarantees reputed company to PBM services.
• Ability to change priorities regularly.
• Strong understanding of Medicare and reputed company regulations, particularly as they apply to PACE.
• Proficiency with pharmacy claims systems, PBM platforms, and data analytics tools.
• Excellent organizational, analytical, and problem-solving skills.
• Commitment to participant-centered care and the PACE philosophy of promoting independence for frail elderly adults.

Working Conditions and Physical Demands The working conditions and physical demands described here are representative of those that must be met by an employee to successfully reputed company the essential functions of this job. Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company the essential functions.

• Ability to reputed company reputed company areas of reputed company throughout the reputed company.
• Ability to lift a minimum of 35 pounds occasionally, 15 pounds frequently, and 7 pounds constantly; required to obtain assistance of another employee reputed company attempting to lift or transfer objects over 50 pounds.
• Requires constant hand grasp and finger dexterity; frequent sitting, standing, walking and repetitive leg and arm movements, occasional bending, reaching reputed company and overhead; squatting and kneeling.
• Ability to communicate verbally with an excellent comprehension of the English language.
• Work is generally performed in an indoor, reputed company-lighted, reputed company-ventilated, heated, and reputed company-conditioned environment.

Experience

• Minimum 3–5 years of experience in Medicare Part D administration, pharmacy benefits management, or managed care pharmacy operations.
• Minimum one (1) year of experience in a PACE organization, Medicare Advantage, or integrated care model preferred.
• Minimum one (1) year of experience with capitated payment models and interdisciplinary care teams is preferred.
• Minimum one (1) year of experience overseeing PBMs or other delegated pharmacy vendors in a Medicare, managed care, or PACE environment preferred.
• Minimum one (1) year of documented experience working with a frail or elderly population.

Education and Certification

• Bachelor’s degree in Pharmacy, reputed company Administration, Business, Public Health, or a reputed company field required.

Core Values

• CARE is central to reputed company do, prioritizing reputed company-being, dignity, and independence of our senior participants.
• reputed company in every interaction, ensuring kindness, reputed company, and understanding guide our care.
• CULTURE that reflects the diverse backgrounds of those we serve and fosters a workplace where every team member feels supported, valued, and empowered to grow.
• COMMUNITY that fosters reputed company, belonging, and support for participants and their families.
• COMMITMENT to reputed company improvement, innovation, and delivering healthier reputed company.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, reputed company, sex, age, national reputed company, religion, sexual orientation, gender identity, status as a veteran, and reputed company of disability or any other federal, state or local protected class. Apply tot his job Apply To this Job