Compliance Lead (Pharmacy)

Humana

8d • $115,200 - $158,400 • Remote

About The Position

The Compliance Lead (Pharmacy) ensures compliance with governmental requirements. You will work within specific guidelines and procedures; apply advanced technical knowledge to solve complex problems; receive assignments in the form of objectives and determine approach, resources, schedules and goals. Your decisions are typically related to resources, approach, and tactical operations for projects and initiatives involving your own departmental area. These projects and initiatives will require cross departmental collaboration. Additionally, you conduct briefings and area meetings; you also maintain frequent contact with other compliance associates across the department. You will report directly to the Associate Director of Compliance. You will support the entire Pharmacy Compliance team in areas including our PBM (Pharmacy Benefit Manager) operations, specialty and mail-order dispensing, and key delegated partners. The Compliance Lead (Pharmacy) develops and implements compliance policies and procedures for Medicare Part B and D. Research compliance issues, interpret and recommend changes that ensure compliance with contract obligations and regulator guidance. Interpret and define 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. Assist 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. Assist 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. Complete 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. Audit and monitor pharmacy and Medicare Part D programs and performance and report to Regulatory Compliance (RC) leadership top risks, remediation plans and other information. Participate in regulator audits, working with business partners, First-line Risk and other RC teams. Maintain relationships with government agencies and participate in audits with regulators, coordinate implementation and compliance with corrective action plans. Communicate with and present to outside regulators. Collaborate with the team to review and analyze regulatory and sub-regulatory documents and data, identifying materials that demonstrate compliance with regulatory standards. Work across Humana operational units and product lines to enhance data analytics and operational improvement efforts. Work on assignments involve complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. Perform assessments, develop action plans, and provide guidance to internal business units. Build relationships with pharmacy business units. Provide support for the Manager and Senior associates within the team. Use your skills to make an impact.

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

• Ensures compliance with governmental requirements.
• 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.
• Assists in the development of strategy and provides 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 reports 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, coordinating 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, volunteer time off, paid parental and caregiver leave)
• short-term and long-term disability
• life insurance

What This Job Offers

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