Pbm Implementation Jobs in Fresno, CA (NOW HIRING)

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.

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) related to pharmacy records.
• Prepare regular oversight reports on PBM performance, compliance metrics, audit findings, participant issues, and corrective action status.
• Trend operational and compliance issues related to pharmacy benefit administration and recommend process improvements.
• Participate in quality improvement and compliance initiatives related to medication safety, pharmacy operations, and delegated entity performance.
• Work closely with the Medical Director, Primary Care Providers, Pharmacy, PBM, and IDT to ensure pharmacy services are aligned with individualized care plans.
• Attend and participate in staff meetings, in-services, projects, and committees as assigned.  
• Adhere to and support the center’s practices, procedures, and policies, including assigned break times and attendance.
• Cooperatively accept assigned duties and perform all other related 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 Driver’s License is required.

Knowledge, Skills and Abilities 

• Proficient knowledge of computer skills. MS Office (Word, Excel, Access, 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 oversight principles, vendor governance, and audit documentation practices in regulated healthcare programs.
• Demonstrated ability to conduct monitoring, auditing, root cause analysis, and corrective action follow-up.
• Ability to interpret vendor contracts and performance guarantees related to PBM services.
• Ability to change priorities regularly.
• Strong understanding of Medicare and Medicaid 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 perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Ability to access all areas of the center throughout the workday.
• Ability to lift a minimum of 35 pounds occasionally, 15 pounds frequently, and 7 pounds constantly; required to obtain assistance of another employee when 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 forward and overhead; squatting and kneeling.
• Ability to communicate verbally with an excellent comprehension of the English language. 
• Work is generally performed in an indoor, well-lighted, well-ventilated, heated, and air-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, Healthcare Administration, Business, Public Health, or a related field required.

Core Values

• CARE is central to what we do, prioritizing the well-being, dignity, and independence of our senior participants. 
• COMPASSION in every interaction, ensuring kindness, empathy, 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 connection, belonging, and support for participants and their families.
• COMMITMENT to quality improvement, innovation, and delivering healthier outcomes.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.