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.
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.
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.
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.
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.
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