Compliance Lead (Pharmacy)

Humana

5d • $115,200 - $158,400 • Remote

About The Position

The Compliance Lead (Pharmacy) ensures compliance with governmental requirements. This role involves working within specific guidelines and procedures, applying advanced technical knowledge to solve complex problems, and receiving assignments with objectives to determine approach, resources, schedules, and goals. Decisions made are typically related to resources, approach, and tactical operations for projects and initiatives involving the departmental area, requiring cross-departmental collaboration. The role involves conducting briefings and area meetings, and maintaining frequent contact with other compliance associates across the department. The Compliance Lead reports directly to the Associate Director of Compliance and supports the entire Pharmacy Compliance team in areas including PBM (Pharmacy Benefit Manager) operations, specialty and mail-order dispensing, and key delegated partners. The role develops and implements compliance policies and procedures for Medicare Part B and D, researches compliance issues, interprets and recommends changes to ensure compliance with contract obligations and regulator guidance, and interprets and defines regulatory and contract requirements for implementation by appropriate Humana Departments and/or external partners to support Pharmacy including Medicare Part D. Additionally, the role assists in the development of strategy and provides ongoing oversight and monitoring of Pharmacy performance, assists the Associate Director and Manager in the completion of risk assessments, completes work functions in assigned areas such as the Medicare Prescription Payment Plan, Integrated Dual Eligible Special Needs Plans (AIP D-SNP), new implementations/CMS initiatives, audits and monitors pharmacy and Medicare Part D programs and performance, participates in regulator audits, maintains relationships with government agencies, communicates with and presents to outside regulators, collaborates with the team to review and analyze regulatory and sub-regulatory documents and data, works across Humana operational units and product lines to enhance data analytics and operational improvement efforts, performs assessments, develops action plans, provides guidance to internal business units, builds relationships with pharmacy business units, and provides support for the Manager and Senior associates within the team.

Requirements

• Bachelor's degree.
• Five (5) years of pharmacy experience in claims operations.
• Four (4) or more years of experience working in a compliance-related, risk management and/or managed care-related field.
• Four (4) or more years interpreting complex regulatory guidance.
• Experience in auditing and consulting.
• Experience working with regulatory agencies, including CMS and/or state departments of health insurance.
• Knowledgeable in regulations governing health care industries.
• Knowledge of PBM (Pharmacy Benefit Manager) operations.
• Demonstrated ability to interpret and translate guidance to various audiences in a highly matrixed setting.
• Highly effective communicator with the ability to influence decision-making and build alignment across diverse stakeholders.

Nice To Haves

• PharmD, Juris Doctorate, or master's degree.
• Certification in healthcare compliance (CHC, CCEP) or similar.

Responsibilities

• Develops and implements compliance policies and procedures for Medicare Part B and D.
• Researches compliance issues, interprets and recommends changes that ensure compliance with contract obligations and regulator guidance.
• Interprets and defines regulatory and contract requirements to be implemented by appropriate Humana Departments and/or external partners to support Pharmacy including Medicare Part D with support of Associate Director.
• Assists in the development of strategy and provide ongoing oversight and monitoring of Pharmacy performance including Medicare Parts B and D and related areas, to ensure full compliance and minimize risk for the Enterprise.
• Assists the Associate Director and Manager in the completion of risk assessments, with latitude in shaping annual work plans to audit and monitor pharmacy performance of areas within the scope of the position for Medicare Parts B and D.
• Completes work functions in assigned areas such as the Medicare Prescription Payment Plan, Integrated Dual Eligible Special Needs Plans (AIP D-SNP), new implementations/CMS initiatives and interpreting complex regulatory guidance to advise pharmacy aligned business areas.
• Audits and monitors pharmacy and Medicare Part D programs and performance and report to Regulatory Compliance (RC) leadership top risks, remediation plans and other information.
• Participates in regulator audits, working with business partners, First-line Risk and other RC teams.
• Maintains relationships with government agencies and participates in audits with regulators, coordinate implementation and compliance with corrective action plans.
• Communicates with and presents to outside regulators.
• Collaborates with the team to review and analyze regulatory and sub-regulatory documents and data, identifying materials that demonstrate compliance with regulatory standards.
• Works across Humana operational units and product lines to enhance data analytics and operational improvement efforts.
• Performs assessments, develops action plans, and provides guidance to internal business units.
• Builds relationships with pharmacy business units.
• Provides support for the Manager and Senior associates within the team.

Benefits

• medical
• dental
• vision benefits
• 401(k) retirement savings plan
• time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
• short-term and long-term disability
• life insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Senior