Compliance Lead (Pharmacy)

About the role

Become a part of our caring community. The Compliance Lead (Pharmacy) ensures compliance with governmental requirements. You will work within specific guidelines and procedures; apply advanced technical knowledge to solve complex problems; receive assignments in the form of objectives and determine approach, resources, schedules and goals. Your decisions are typically related to resources, approach, and tactical operations for projects and initiatives involving your own departmental area. These projects and initiatives will require cross departmental collaboration.

Responsibilities

• Work within specific guidelines and procedures; apply advanced technical knowledge to solve complex problems.
• Receive assignments in the form of objectives and determine approach, resources, schedules and goals.
• Conduct briefings and area meetings; maintain frequent contact with other compliance associates across the department.
• Support the entire Pharmacy Compliance team in areas including our PBM (Pharmacy Benefit Manager) operations, specialty and mail-order dispensing, and key delegated partners.
• Develop and implement compliance policies and procedures for Medicare Part B and D.
• Research compliance issues, interpret and recommend changes that ensure compliance with contract obligations and regulator guidance.
• Interpret and define regulatory and contract requirements to be implemented by appropriate Humana Departments and/or external partners to support Pharmacy including Medicare Part D with support of Associate Director.
• Assist in the development of strategy and provide ongoing oversight and monitoring of Pharmacy performance including Medicare Parts B and D and related areas, to ensure full compliance and minimize risk for the Enterprise.
• Audit and monitor pharmacy and Medicare Part D programs and performance and report to Regulatory Compliance (RC) leadership top risks, remediation plans and other information.
• Participate in regulator audits, working with business partners, First-line Risk and other RC teams.
• Maintain relationships with government agencies and participate in audits with regulators, coordinate implementation and compliance with corrective action plans.
• Communicate with and present to outside regulators.
• Collaborate with the team to review and analyze regulatory and sub-regulatory documents and data, identifying materials that demonstrate compliance with regulatory standards.
• Work across Humana operational units and product lines to enhance data analytics and operational improvement efforts.
• Perform assessments, develop action plans, and provide guidance to internal business units.
• Build relationships with pharmacy business units.
• Provide support for the Manager and Senior associates within the team.

Requirements

• Bachelor's degree.
• Five (5) years of pharmacy experience in claims operations.
• Four (4) or more years of experience working in a compliance-related, risk management and/or managed care-related field.
• Four (4) or more years interpreting complex regulatory guidance.
• Experience in auditing and consulting.
• Experience working with regulatory agencies, including CMS and/or state departments of health insurance.
• Knowledgeable in regulations governing health care industries.
• Knowledge of PBM (Pharmacy Benefit Manager) operations.
• Demonstrated ability to interpret and translate guidance to various audiences in a highly matrixed setting.
• Highly effective communicator with the ability to influence decision-making and build alignment across diverse stakeholders.

Preferred Qualifications

• PharmD, Juris Doctorate, or master's degree.
• Certification in healthcare compliance (CHC, CCEP) or similar.