Senior Compliance Professional

Humana

6d • $86,300 - $118,700 • Remote

About The Position

The Senior Compliance Professional ensures adherence to government regulations and requirements. Your role will involve work assignments of moderate to high complexity, requiring comprehensive analysis and evaluation of variable factors and data. The primary focus of this position is compliance related to Medicare Pharmacy and Part D programs. The Senior Compliance Professional will analyze business requirements, conduct research, and provide regulatory interpretation to advise internal business units and external business partners. This guidance supports the delivery of results that minimize compliance risk exposure for Humana. You will be responsible for developing and maintaining key relationships with Humana operational leaders and external business partners. The primary focus of this role is to develop and implement monitoring and auditing plans for business processes. The objective of these plans is to prevent, detect, and resolve compliance issues related to Humana's pharmacy services across segments. While working within assigned areas to optimize business results, the Senior Compliance Professional will: Oversee pharmacy compliance for the Centers for Medicare & Medicaid Services (CMS) Program Audit focused areas, including but not limited to Formulary Administration, Coverage Determination, and Organization Determination (Part B drugs) functions. Cultivate relationships with key partners to ensure compliance alignment on strategic initiatives. Research, understand and apply laws, regulations, and regulatory guidance as applicable for pharmacy services across various segments. Conduct risk assessments and perform auditing and monitoring activities to prevent and detect issues of noncompliance and provide guidance on remedial actions to strengthen compliance controls and ensure compliance with state and federal laws and regulations. Develop and track compliance metrics to help monitor and detect potential compliance issues. Present findings of monitoring and auditing efforts to business partners and Enterprise Compliance leaders and track issues to ensure appropriate and timely remediation. Oversee development and progress of issue remediation; review and analyze documents and data to identify what can be used to evidence meeting regulatory standards. Provide back-up and support to other Enterprise Compliance team members and perform other duties, as needed. Work across Humana operational units and product lines to enhance data analytics and operational improvement efforts. Support resolution of CMS inquiries including analyzing complaints, questions, and complex situations.

Requirements

• Bachelor's degree or three (3) years or more years of demonstrated experience in pharmacy and compliance.
• Three (3) or more years of experience in pharmacy operations and/or claims processing within a pharmacy setting.
• Two (2) or more years of experience in health plan compliance or health plan operations.
• Experience in pharmacy Coverage Determination, and Organization Determination (Part B drugs) functions.
• Experience working with regulatory agencies.
• Intermediate proficiency in Microsoft Excel, Word and PowerPoint.
• Knowledgeable in process improvement and metrics development.
• Knowledgeable in regulations governing health care industries.
• Strong communication skills to lead meetings and communicate with business partners.
• Proven ability to work independently, manage time effectively, and deliver results with minimal supervision.

Nice To Haves

• Juris Doctorate or master's in business administration (MBA).
• Familiarity with Medicare pharmacy laws or regulations.

Responsibilities

• Oversee pharmacy compliance for the Centers for Medicare & Medicaid Services (CMS) Program Audit focused areas, including but not limited to Formulary Administration, Coverage Determination, and Organization Determination (Part B drugs) functions.
• Cultivate relationships with key partners to ensure compliance alignment on strategic initiatives.
• Research, understand and apply laws, regulations, and regulatory guidance as applicable for pharmacy services across various segments.
• Conduct risk assessments and perform auditing and monitoring activities to prevent and detect issues of noncompliance and provide guidance on remedial actions to strengthen compliance controls and ensure compliance with state and federal laws and regulations.
• Develop and track compliance metrics to help monitor and detect potential compliance issues.
• Present findings of monitoring and auditing efforts to business partners and Enterprise Compliance leaders and track issues to ensure appropriate and timely remediation.
• Oversee development and progress of issue remediation; review and analyze documents and data to identify what can be used to evidence meeting regulatory standards.
• Provide back-up and support to other Enterprise Compliance team members and perform other duties, as needed.
• Work across Humana operational units and product lines to enhance data analytics and operational improvement efforts.
• Support resolution of CMS inquiries including analyzing complaints, questions, and complex situations.

Benefits

• medical, dental and 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
• many other opportunities

What This Job Offers

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