Job Description: Looking for a way to make an impact and help people?
Join PacificSource and help our members access quality, affordable care!
PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.
Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.
Position Overview: Support all aspects of the pharmacy services compliance program for Medicare, Medicaid and Commercial lines of business. Assume the primary role of interfacing with the Compliance department, auditors, vendors and pharmacy staff for purposes of monitoring and ensuring compliant pharmacy operations. Interface with the Compliance Department and Fraud, Waste and Abuse teams to evaluate and address fraudulent activities impacting the Pharmacy Department. Conduct internal audits, support external audits, develop policies and procedures, and ensure departmental compliance.
In partnership with Internal Auditors, Compliance staff and Pharmacy leadership, develop formal internal auditing and monitoring plans to assess pharmacy compliance with all State, Federal and internal business rules and regulations.
Serve as an inter-departmental liaison for pharmacy compliance and FWA activities.
Evaluate pharmacy operations, including workflow decisions to ensure that clinical and administrative programs are compliant with State, Federal and internal business rules and regulations.
Conduct independent reviews to ensure compliant processes are in place on all Pharmacy Services business operations, including but not limited to: formulary administration, coverage determination processing, appeals and grievance processing, organizational determinations, OIG status, FWA programs, helpdesk operations including call monitoring, communication strategies, website publications, medication therapy management operations, claims adjudication, PDE processing and all vendor managed programs.
Responsible for the research of applicable Medicare, Medicaid and NCQA rules and regulations and pharmacy team education on any new rules or regulations.
Investigate, analyze, and provide recommendations related to compliance findings, including assessments and impact reports, and corrective actions.
Perform routine independent and objective monitoring activities of all Pharmacy Services business operations, publish results and report out to Pharmacy leadership, Compliance Department, quality committees and other PacificSource leadership teams as applicable.
Respond to all compliance related inquiries from internal Compliance Department staff and external auditors in a timely, professional and accurate manner to ensure minimal organizational and operational impact.
Develop Pharmacy Department policies and procedures as applicable and ensure regular maintenance to reflect new practices and guidance.
Provide interpretation, training, and implementation of Medicare, Medicaid, and Commercial regulations and communicate them appropriately with respective departments and teams.
Provide oversight of Pharmacy Benefit Manager operations through the following actions: attending weekly meetings; review and approve external communications; and monitor operational performance reports.
Support FWA efforts by identifying cases, conducting preliminary research, and interfacing with the FWA team on findings.
Support NCQA best practices, including operational processes and policy development.
Support ongoing communication efforts. Maintaining compliant member, pharmacy and provider communications updates in accordance to current models and best practices.
Meet department and company performance and attendance expectations.
Perform other duties as assigned.
Work Experience: Minimum of four years of healthcare or health insurance industry required. Strong preference for experience in auditing or compliance related role.
Education, Certificates, Licenses: Bachelor's degree strongly preferred. An equivalent combination of education and healthcare (or health insurance industry) experience will be considered.
Knowledge: Understanding of Medicare and Medicaid rules and regulations preferred. Strong computer skills. Highly proficient verbal and business writing skills. Understanding of Medical Terminology preferred. Ability to work under strict timelines and pressure situations. Requires ability to define and prioritize problems and manage workload without direct supervision.
Building Customer Loyalty
Building Strategic Work Relationships
Contributing to Team Success
Planning and Organizing
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.
We are committed to doing the right thing.
We are one team working toward a common goal.
We are each responsible for customer service.
We practice open communication at all levels of the company to foster individual, team and company growth.
We actively participate in efforts to improve our many communities-internally and externally.
We encourage creativity, innovation, and the pursuit of excellence.
Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.