Job Category: Compliance, Medicaid, Project Management
Clinical Licensure Required : N/A
Job Type: Full Time Position Summary:
The Medicaid Regulatory Advisor position has a direct impact on how our clients view our compliance with federal and state Medicaid regulations for each of our clients' markets, and has a direct correlation with their confidence in CVS Caremark's ability to administer their plans from a state regulatory oversight perspective. In the role as a Medicaid Regulatory Advisor, this position will serve as subject matter expert for Medicaid guidance and regulations. Drive all aspects of the state Medicaid regulations in order to ensure that CVS Caremark Operations is fully compliant. Collaborate with key functional leaders to drive compliance for regulatory requirements in the business processes and system enhancements required to meet those standards. Identify and escalate possible impacts and associated business risks to Sr Leadership.
This position is responsible for understanding federal and state Medicaid regulations end-to-end for the areas that it supports, e.g., claims adjudication, clinical programs, beneficiary materials, prior authorization and appeals, encounter processing, network requirements, etc., for the Medicaid plans we service. As part of fully understanding the federal and state Medicaid regulations, this position will have the following responsibilities to support CVS Caremark's organization:
1) Be the key decision-maker and person to resolve escalated issues with our Medicaid clients that can't be resolved through standard avenues. Attend client calls to resolve regulatory interpretation issues between us and our Medicaid plans, work through complex issue resolution and negotiate the solution, hold scheduled calls as requested to review new regulations (typically requested by key clients). Must be up to speed on commonly referenced Medicaid regulations and have the ability to answer complex client questions on the spot. Organize and conduct client webinars on various topics, when needed. Write client communications that explain CVS Caremark's responsibilities related to compliance with Medicaid regulations. These communiations must be accurate and concise as our clients use them to articulate how their PBM Contractor (us) is following Medicaid regulations. Attend client audits and support follow up activities as requested with quick TAT on analysis and subsequent resolution that meets the needs of state Medicaid regulators and our clients.
2)Ensure that CVS Caremark is in compliance with federal and state Medicaid regulations for the services that our PBM clients delegate to us. Ensuring compliance includes maintaining/updating regulatory baselines. When regulations change, assisting the Medicaid operations' teams with conducting a compliance gap analysis, coordinating with a Project Manager to assist operations with remediation activities, and review policies and procedures for accuracy and completeness. After CVS Caremark operations has made necessary change, assist with drafting client communications/preparing webinars for clients. Position will work closely with the account teams and implementation teams to review client information to determine if there is a regulatory impact.
3)Support the operations and account teams by conducting research on state and federal Medicaid requirements. If a gap in compliance is identified, then the position will complete the activities outlined in #2.
Failure to implement new regulations/requirements "accurately" and "on time" could result in the following:
a. Severe negative financial implications to CVS Caremark, or their clients
b. Loss of clients and inability to attract new ones
c. Service Warranties or Performance Guarantees paid to the client due to non-compliance
d. Audits at the request of the state Medicaid regulator Required Qualifications:
9 plus years of significant regulatory experience Medicaid - preferred, PBM experience a minimum of 5 years or a combination of PBM and regulatory experience may be a substitute. Experience with formal presentations in large forums preferred. Client-facing experience of at least 3 years preferred. Preferred Qualifications:
Significant Medicaid knowledge mandatory. Ability to work with and influence crossfunctional to implement new requirements effectively - very strong interpersonal skills required. Ability to understand technical process flows and understand complex requirements. Requires the ability to understand complex mathematical calculations and how plan design can impact Caremark's ability to meet state regulatory guidelines. Ability to "project manage" deliverables across multiple departments and follow-up to ensure completion. Ability to drive to solution quickly cross-functionally to meet state and client timeframes. Knowledge of Prescription Benefit Management industry Knowledge of Microsoft Office Suite with a focus on Excel, Powerpoint, Word, Outlook or Lotus Notes and Web applications Excellent verbal and written communication skills (be comfortable articulating complex issues to all levels of management). Excellent presentation skills - ability to present and communicate effectively at webinars for internal business partners and external clients Excellent organizational and time management skills Excellent interpersonal and collaborative skills Able to work in fast paced and changing work environment with quick turnaround Able to work collaboratively with people in a team environment Able to work independently Requires attention to detail Ability to meet deadlines with a variety of responsibiliities Ability to work effectively with multiple functional areas Ability to exercise professional judgement in analyzing and resolving client issues Ability to creatively solve problems when dealing with a variety of variables in situations where standard resolutions do not exist Ability to thoroughly explain impacting results to internal and external clients. Education:
Bachelor's degree required. An equivalent combination of education and experience may substitute. Business Overview:
CVS Caremark, through our unmatched breadth of service offerings, is transforming the delivery of health care services in the U.S. We are an innovative, fast-growing company guided by values that focus on teamwork, integrity and respect for our colleagues and customers. What are we looking for in our colleagues? We seek fresh ideas, new perspectives, a diversity of experiences, and a dedication to service that will help us better meet the needs of the many people and businesses that rely on us each day.
As the nation’s largest pharmacy health care provider, we offer a wide range of exciting and fulfilling career opportunities across our three business units – MinuteClinic, pharmacy benefit management (PBM) and retail pharmacy. Our energetic and service-oriented colleagues work hard every day to make a positive difference in the lives of our customers.
CVS Health is a pharmacy innovation company helping people on their path to better health. Through our 7,800 CVS/pharmacy retail pharmacies,...