The Lead Medicare Regulatory Specialist will be assigned to and work closely with the Pharmacy department to lead Emblem’s efforts to analyze Medicare Pharmacy-related policy and interpret and implement CMS rules and guidance related to Medicare Part D. The Pharmacy Lead will provide Medicare regulatory and operational subject matter expertise, both clinical and administrative, for analysis of Pharmacy policy and interpretation, testing, monitoring and adherence to Medicare Part D requirements. This Lead position in intended to play a leadership role, bringing together the Pharmacy Department, Medicare Product and other departments to help to fill existing knowledge, skill and monitoring gaps while increasing oversight and support for critical Medicare operational improvement and other activities. This position will work with Pharmacy operations staff to identify, interpret, and communicate new and revised CMS regulatory requirements. Responsibilities include analysis of existing policies and procedures for the purpose of achieving operational excellence, and implementation of new or revised regulatory changes, monitoring, tracking, and testing implementation of all Medicare requirements for Part D. Operational oversight of P&Ps, of the DIR report, Drug Utilization Review, Mediation Therapy Management Program, Transition Policy and PDE Reconciliation are key components of this position.
As a result of CMS monitoring, the Lead Medicare Regulatory Specialist for Pharmacy, working under the Director of Medicare Regulatory Implementation and Coordination, will collaborate with the Pharmacy department leadership to improve operational capabilities, and to construct the corrective action plans that best supports our internal process and resources, while fully responding to the issues identified by CMS. The Lead Medicare Regulatory Specialist ensures that resolutions are implemented in a timely fashion. The Lead Specialist will maintain tools that track and accurately record all operational and compliance issues, assure successful implementation of required changes and adherence to quality standards.
The Lead Specialist will also implement processes and reports that will assist management in identifying and stratifying existing and potential operational issues that impact EmblemHealth’s Medicare Part D program. The Lead Specialist will work with the Pharmacy department’s management on a day to day basis to implement changes aimed at operational improvement and proactive management of risk areas, provide data and reports that will assist the Director in identifying operational improvements and in creating responses to CMS issues. The Lead Specialist will produce routine and ad hoc operational reports for Part D to management as required, will assist management in the Pharmacy department in the resolution of regulatory compliance issues, as well as provide regulatory guidance.
• Analyze policies, procedures and work processes throughout the company that are related to Medicare Part D in order to identify potential operational improvements that will provide a better customer experience and support improvements in EH’s quality ratings. Lead company efforts to implement changes so identified.
• Review and interpret CMS guidance related to Part D operational policies outlined in the Prescription Drug Benefit Manual. Dissemination of CMS guidance to Pharmacy department for implementation of processes. Review guidance to identify and stratify existing and potential operational issues that impact EmblemHealth’s Medicare product from a regulatory perspective. This includes, but is not limited to, Regulatory oversight of Formulary Administration, Drug Utilization Review, Mediation Therapy Management Program, Transition Policy and PDE Reconciliation and Direct and Indirect Remuneration (DIR) reporting.
• As a result of CMS monitoring, oversee the coordination with Pharmacy department’s leadership to construct the corrective action plan that best supports our internal processes, while fully responding to the CMS issues identified.
• Work with the Pharmacy department’s management on a day to day basis to implement changes aimed at proactive management of risk areas, provide data and reports that will assist in creating responses to CMS issues.
• Producing routine and ad hoc Pharmacy compliance reports to management as required will assist management in the functional areas in the resolution of regulatory compliance issues, as well as providing regulatory guidance.
• Lead large scale projects and collaborate efforts for maintenance and development of Medicare program initiatives related to Part C and Part D regulations. Support the development of regulatory and operational business requirements for ‘best practice’ implementation of Medicare rules and regulations.
• Regular attendance is an essential function of the job. Performs other duties as assigned or required.
Position Success Criteria:
Apply knowledge of Medicare D regulations, as well as health plan operations knowledge to operational compliance issues identified by CMS, OIG, NYS and other governmental oversight entities. Work successfully with Pharmacy department staff to provide guidance and assist in the implementation of best practices related to these issues, and collect and manage data and reports as needed to assure management that EmblemHealth has corrected the issue and has sufficient oversight in place to ensure that issues will not recur.
• Implement process changes to bring the Pharmacy operation into full compliance with regulatory requirements pertaining to Medicare operations, provide data and reporting that will assist management in planning enhancements to the Medicare operational monitoring process, and work directly with Pharmacy department to ensure that processes are in place that minimize regulatory risk to the plan.
Education and Experience:
• Bachelor’s Degree in Pharmacy, Doctorate of Pharmacy preferred.
• Minimum eight to ten years’ work experience in Medicare healthcare operations or Medicare compliance required.
• Thorough knowledge of Medicare Advantage and Medicare Prescription Drug Programs operations and regulations required.
• Proficiency in the use of Microsoft Office (Word, Excel and Access) required.
• Strong analytical skills required.
• Proven ability to establish and maintain relationships of trust with departmental staff and management
• Proven ability to coordinate and lead interdepartmental work teams and meet established goals.
• Must be goal oriented and able to meet tight deadlines while handling multiple priorities.
• Must be a team player and able to take direction from multiple sources.
• Must be highly organized, able to handle multiple assignments with overlapping deadlines. Must have the ability to show attention to detail.
• Excellent communication skills (written and verbal) required. Ability to communicate clearly and concisely with EmblemHealth staff and management.
• Ability to arrange work schedule to meet deadlines from multiple sources, and engage staff throughout EmblemHealth to assist in the completion of duties.
Internal Posting Expires: 2/21/13
EmblemHealth is set on being the mark of good health in the Northeast. The not-for-profit company provides health...