Manager, Pharmacy Compliance, Regulatory & Accreditation

The Manager of Pharmacy Compliance, Regulatory, and Accreditation ensures pharmacy services comply with federal, state, and accreditation agency regulations and standards. This position includes oversight of The Health Plan's relationship with its PBM, the assessment of outcomes for quality improvement, Medicare (Part D) required reporting, monitoring FIR transactions, PDE reconciliation, CMS audits, report preparation for CMS and NCQA audits, policy and procedures, and FDR oversight of pharmacy vendors.

Required:

1. Managed care pharmacy experience.
2. Ability to work and make decisions independently.
3. Ability to complete appropriate program-specific training as applicable.
4. Possesses public speaking and written communication skills, motivation, and initiative.
5. Ability to multi-task and prioritize work.
6. Strong analytical and problem-solving skills.
7. At least two years of experience working with CMS and NCQA requirements and standards.
8. Experience developing and reviewing CMS and NCQA audit universes.
9. Possesses demonstrated knowledge in Microsoft Office programs (e.g. Microsoft Word, Excel, Outlook, PowerPoint) with proficient keyboarding and computer literacy skills and the ability to navigate multiple systems.

Desired:

1. Five to seven (5 -7) years managed care pharmacy experience.
2. Two years of experience in a supervisory capacity.
3. National Pharmacy Technician Certification.

Responsibilities:

1. Works closely with pharmacy department leadership and the compliance department to ensure compliance within all areas of pharmacy services.
2. Maintain compliance policies and procedure documents for operations of the pharmacy services department.
3. Monitors performance of pharmacy department workflow processes in accordance with CMS and NCQA compliance.
4. Partners with pharmacy department leadership to review, develop and ensure execution on departmental policies and procedures in conjunction with all applicable state, federal, and contractual requirements and
5. Ensures that coverage determination requests are handled in accordance with federal and state regulatory compliance time frames.
6. Manages day-to-day pharmacy audit functions and adjusts activities in response to audit findings.
7. Partners with the SIU unit to prevent and detect fraud, waste and abuse.
8. Partners with the compliance and SIU departments to review and act upon Part D alerts as applicable.
9. Ensures adherence to CMS, regulatory, and NCQA clinical requirements.
10. Assists in tracking and follow-up (as needed) of identified issues at the PBM level to include corrective actions and self-disclosure with tracking in OMT.
11. Attends and serves as a pharmacy representative for Medicare Workgroup, CQI, CMS plan manager calls and other internal meetings.
12. Conducts regular quality checks ensuring consistency of data.
13. Coordinates the quarterly PBM Business Review meetings including written report of outcomes to be provided to pharmacy services department leadership.
14. Works with PBM and internal partners to develop corrective strategies and communicate downstream impacts of issues and opportunities to all necessary business partners.
15. Works with PBM to ensure clinical intent setup meets CMS, regulatory, and NCQA clinical requirements.
16. Works with external vendors to ensure contracted programs meet CMS, regulatory, and NCQA clinical requirements.
17. Works with PBM and internal partners to monitor and correct PDE rejects and deletions.
18. Completes monthly, quarterly, and yearly OMT indicators as assigned.
19. Completes appropriate program specific training as applicable.
20. Organizes and runs the quarterly pharmacist meeting including all clinical and operational documentation.
21. Develops and implements corrective action plans as needed
22. Communicates significant compliance-related issues to the compliance department.
23. Reviews and performs quality checks on a regulatory data sets such as universes used for CMS program audits and data used for annual CMS Part D reporting.
24. Represents the pharmacy department during regulatory audits including preparation and document collection activities.
25. Educates pertinent staff in accordance with the compliance department corrective action plans, CMS, or NCQA audit findings.
26. Reviews utilization management denial verbiage to ensure compliance with CMS and NCQA requirements and standards.