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.
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.
To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:
As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.
