Part D Administrator

**Who We Are** PACE by IIH is empowering senior participants to age at home with dignity through personalized, comprehensive care plans that deliver high-quality health and human services along with strong community support. Through an interdisciplinary and participant-centered model of care, PACE by IIH is committed to improving quality of life, promoting independence, and providing compassionate support tailored to the unique needs of each participant. Our team works collaboratively to deliver innovative, community-based healthcare solutions that allow seniors to remain safely and comfortably in their homes while receiving the care and services they need to thrive. **Benefits** - 401(k) - Dental insurance - Employee assistance program - Employee discount - Flexible spending account - Health insurance - Health savings account - Life insurance - Paid sick time - Paid time off - Referral program - Retirement plan - Vision insurance **Job Summary** The Part D Administrator is responsible for the effective administration of the Medicare Part D prescription drug benefit within the PACE organization and for oversight of delegated pharmacy benefit functions performed by the pharmacy benefit manager (PBM) and other contracted vendors. This role ensures compliance with all applicable Centers for Medicare & Medicaid Services (CMS) Part D requirements and PACE requirements, including monitoring delegated entity performance, conducting oversight activities, supporting audit readiness, and implementing corrective actions when deficiencies are identified. # Essential Job Functions Duties include, but are not limited to: - - Oversee daily operations of the Part D benefit, including benefit design, coordination of benefits, and integration with PACE’s comprehensive medical and social services. - Manage the annual Part D bid submission process and formulary development/submission (as required by CMS). - Ensure accurate and timely submission of Prescription Drug Event (PDE) records to CMS, including handling updates related to Inflation Reduction Act (IRA) changes (e.g., manufacturer discounts, TrOOP accumulator tracking). - Maintain compliance with all applicable Medicare Part D regulations (42 CFR Part 423), PACE-specific requirements (42 CFR Part 460), and CMS guidance for PACE Part D sponsors. - Develop, implement, and monitor policies and procedures for pharmacy benefits, including quality 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 related to Part D activities. - Prepare for and respond to CMS audits, reporting requirements, and data submissions. - Oversee pharmacy claims adjudication, point-of-sale processing, and coordination with contracted pharmacy benefit managers (PBMs), pharmacies, and long-term care facilities. - Oversee PBM claims adjudication processes, including testing, reconciliation, exception handling, and operational issue resolution. - Monitor pharmacy network access, long-term care pharmacy support, and transition processes to ensure participant access 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 IDT and prescribers. - Track participant drug utilization, identify high-risk or high-cost medications, and implement strategies to optimize therapy and control costs within the capitated PACE model. - Manage participant grievances, coverage determinations, appeals, and exceptions processes for prescription drugs. - Educate IDT members, participants, and caregivers on Part D benefits while providing staff with training, guidance, and best practices on Part D policies and procedures. - Ensure privacy and security of protected health information (PHI)…