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.
Use your skills to make an impact
Required Qualifications
- Three (3) or more years ofexperience in pharmacy claims processing and/or pharmacy claims research.
- Two (2) or more years of experience in health plan compliance or health plan operations.
- Experience in pharmacy Coverage Determinations for Medicare Part D and/or Organization Determinations for Medicare Part B drugs.
- Experience creating and utilizing PivotTables, VLOOKUPs, and other Excel functions to analyze, research, and validate claims data.
- Experience working with regulatory agencies, including CMS and/or state departments of health insurance.
- Knowledge of PBM (Pharmacy Benefit Manager) operations.
- Knowledgeable in process improvement and metrics development.
- 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.
Preferred Qualifications
- Bachelor's degree, master's degree in business administration (MBA) or Juris Doctorate.
- Familiarity with Medicare pharmacy laws or regulations.
Additional Information
- Workstyle: This is a remote position.
- Travel: This role may require up to 5% of travel for onsite meetings, which could include locations outside your state of residence.
- Work Schedule: Monday–Friday, Eastern Standard Time (EST), with some flexibility to accommodate other time zones. We will discuss specific scheduling options during the interview process.
Work at Home Requirements: 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: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
Scheduled Weekly Hours
40
Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
$86,300 - $118,700 per year
This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and 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 and many other opportunities.
