Compliance Professional 2 (Pharmacy Health Plan Operations) - Remote, FL

Humana Inc. Jacksonville , FL 32277

Posted 2 months ago

Description

The Compliance (UM) Professional 2 conducts and summarizes compliance audits. The Compliance (UM) Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities

The Compliance (UM) Professional 2 collects and analyzes data daily, weekly, monthly or as needed to assess outcome and operational metrics for the team and individuals. Ensures mandatory reporting completed.

  • Reviews and interprets new CMS and regulatory requirements and works with the business area to ensure compliance with requirements.

  • Manages tasks and timelines to ensure compliance with regulatory initiatives.

  • Conducts quality assurance audits of Part D coverage determinations to ensure compliance requirements and internal processes are being followed.

  • Generation and data scrubbing of CMS ODAG/CDAG audit universes including source system validations.

  • Reviews and validates monthly pharmacy compliance metrics and works with the pharmacy business area to identify root cause and implement corrective action plan for any non-compliant metrics.

  • Works with the pharmacy business area in updating policies and procedures.

  • Attends assigned compliance meetings and acts as the liaison between the HSO compliance team and pharmacy business area.

  • Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas.

  • Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.

  • Follows established guidelines/procedures.

Required Qualifications

  • 1-2 years of work experience in any of the following; compliance, auditing, health plan, utilization management, or coverage determinations within the pharmacy department.

  • Strong analytical and attention to detail skills.

  • Self-motivated with an ability to manage multiple priorities and work under pressure to meet deadlines.

  • Ability to interact effectively with associates across all levels of the organization.

  • Excellent interpersonal, written, and oral communication skills.

  • Must be passionate about contributing to an organization focused on continuously improving consumer experiences.

  • Comprehensive knowledge of all Microsoft Office applications.

  • Must have a room in your home designated as a home office; away from high traffic areas where confidential information may be secured.

  • Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required.

Preferred Qualifications

  • Associate's or Bachelor's Degree.

  • Certification(s) relevant to area of expertise, such as certification in healthcare compliance (CHC).

  • 1-2 years of work experience in a compliance or auditing function.

  • Knowledge of Part D CMS regulations pertaining to compliance in a managed care health plan.

  • Bilingual (English, Spanish) a plus.

Additional Information

  • Work Days/Hours: Monday - Friday; 8:00 AM - 5:00 PM EST.

  • Benefit package that starts your 1st day of employment.

  • Robust 401k plan through Charles Schwab.

  • Eligibility for associate wellness and rewards program.

  • Opportunity to learn the industry and build professional career.

  • Tuition Reimbursement & Student Loan Refinancing.

Interview Format

As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

Scheduled Weekly Hours

40

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