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Summary: 

Subject matter expert (SME) in Medicare Part D/Commercial Pharmacy compliance.Responsible for communicating Medicare regulatory requirements to operational areas within their SME purview and conducting follow up to assure implementation. Analyzes and clarifies guidance as required for the business area and obtains clarification of guidance from CMS as appropriate. Identifies possible compliance issues, assists with investigation and resolution, escalating issues when appropriate. Assists with monitoring to measure compliance with CMS regulations and guidance, communicates findings to impacted business areas and completes follow up to assure resolution of the identified issues.

 Responsibilities: 

• Provide regulatory interpretation, analysis and make recommendations to management for all aspects of Medicare Part D/Commercial Pharmacy compliance
• Work proactively to ensure business areas falling within their purview are prepared for CMS audits, aware of current guidance and can produce a compliant universe
• Review indicators and other monitoring tools impacting their SME area, spot trends and identify potential compliance issues, providing feedback to business areas and escalating as required
• Effectively using the Corrective Action Plan policy and procedure to correctly and completely document identification and remediation of all compliance issues impacting their SME area
• Coordinate with business area to review regulations, implement corrections if necessary and track completion
• Develop Tracers for CPE audits with moderate supervision and assist business areas in doing the same
• Coordinate with business area partners to ensure reported issues are updated weekly on the CMS Disclosed Issues Grid
• Help ensure business areas within their SME purview are engaged and prepared to report results at all compliance committees and workgroups
• Act as a liaison between CMS Regional Offices and Independence when needed
• Conduct monthly Call Center Monitoring reviewing customer service calls and providing feedback as appropriate
• Able to back up another SME area
• Other duties as assigned

QUALIFICATIONS

• • Bachelor’s degree in related field or equivalent work experience.
  • Minimum of 3 years related work experience in managed care or health care, particularly experience working in a Pharmacy compliance/operational role at another health plan, or at a PBM.
  • Excellent organizational, verbal and written communication skills required.
  • Working knowledge of Microsoft Office products required. Previous compliance experience is preferred.
  • Knowledge of Government Markets, and specifically the pharmacy industry, is an asset.
  • Knowledge of Medicare Advantage Part D regulations.