Regulatory Performance Manager (Pharmacy)

Independence Blue Cross   •  

Philadelphia, PA

Industry: Accounting, Finance & Insurance


8 - 10 years

Posted 72 days ago

This job is no longer available.

Independently manages compliance of all facets of the Part D and Affordable Care Act (ACA) pharmacy programs, including (but not limited to) claims processing, benefits administration, and formulary administration.

  • · Works directly with the Medicare Compliance Officer, the Director of Regulatory Performance Management (RPM) and the Director of Consumer Regulatory Performance Management (RPM) to ensure the Plan’s compliance with CMS regulations related to pharmacy benefits. Independently manages day-to-day oversight of the pharmacy programs, and reports issues and concerns to the Manager of Medicare Compliance or to the Medicare Compliance Officer, the Director of RPM or the Director of Consumer RPM as needed.
  • · Works with the Senior Director Pharmacy Services (and staff) to ensure Plan and PBM compliance with all CMS regulations. This includes performance monitoring utilizing the Online Monitoring Tool (OMT).
  • · Reviews and interprets CMS regulations and guidance as it pertains to the Part D and ACA pharmacy programs and manages responses to ensure that guidance is appropriately implemented by the Plan and/or the PBM.
  • · Works collaboratively with Pharmacy Services (and other functional areas as appropriate) as compliance issues are identified to perform root cause analysis when issues are identified, and manage corrective action responses to ensure they are implemented appropriately.
  • · Serves as the RPM lead for cross-functional projects. Provides support to the RPM Senior Coordinators when issues arise.
  • · Responsible for managing responses for the annual Part D Readiness Assessment.
  • · Represents RPM on workgroups requiring pharmacy expertise.
  • · Serves as the RPM lead for Part D for both internal and external audits, including CMS audits.
  • · Serves as the ACA RPM lead for pharmacy audits conducted by internal or external agencies.
  • · Serves as the RPM subject matter expert (SME) for CMS Regional Office related to pharmacy issues/topics.
  • · Provides support and expertise to other business areas related to Part D and ACA pharmacy benefits, including but not limited to providing targeted trainings and one-on-one support when requested/needed.
  • · Serves as the RPM liaison to the Delegation Oversight department on issues related to Part D and ACA pharmacy benefits and provides support in their oversight of the PBM. This includes attending the Delegation Oversight Quality Meetings, and partnering with Delegation Oversight to issue and review corrective action plans submitted by the PBM.
  • · Serves as the SME for marketing materials review related to Part D benefits to ensure they are accurate as part of the material review process.
  • · Performs other duties as needed, to assist in the overall success of IBC’s compliance program.
    • · Current Certified Pharmacy Technician (CPhT)-Must keep certification active while in this position
    • · At least 7-10 years of specialized Part D experience, preferably with a PBM
    • · Medicare Compliance experience a plus
    • · ACA pharmacy benefits experience a plus
    • · Ability to work independently and manage all compliance functions related to Part D and ACA pharmacy benefits
    • · Working knowledge of CMS guidance related to Part D, and all regulation related to the ACA Pharmacy benefits
    • · Bachelor’s Degree