Compliance Lead, Pharmacy

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $115.2k - $158.4k / year

⏰ Full Time

🟠 Senior

🚔 Compliance

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Humana

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1961

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Humana is a healthcare company dedicated to making a positive impact on the health of individuals, communities, and the healthcare system as a whole. With a focus on putting health first, Humana serves a diverse range of populations, including seniors and the military, providing Medicare Advantage HMO, PPO, and PFFS plans. Humana is committed to fostering a culture of belonging and mutual respect, offering competitive and flexible benefits to ensure the financial security of its employees and their families. The company prides itself on creating an inclusive workplace where everyone has the opportunity to succeed.

📋 Description

• Ensure compliance with governmental requirements for Pharmacy operations • Develop and implement compliance policies and procedures for Medicare Part B and D • Research compliance issues and recommend changes addressing contract obligations and regulator guidance • Interpret regulatory and contract requirements for Humana departments and external partners • Develop strategy and provide ongoing oversight and monitoring of Pharmacy performance • Assist with risk assessments and shape annual audit and monitoring work plans • Complete compliance work for the Medicare Prescription Payment Plan, AIP D-SNP, new implementations, and CMS initiatives • Audit and monitor pharmacy and Medicare Part D programs and report top risks and remediation plans to Regulatory Compliance leadership • Participate in regulator audits and coordinate corrective action plan implementation • Maintain relationships with government agencies and present to outside regulators • Review and analyze regulatory documents and data to demonstrate compliance • Collaborate across operational units and product lines on data analytics and operational improvement • Perform assessments, develop action plans, and advise internal business units • Build relationships with pharmacy business units • Support the Compliance Manager and Senior associates • Conduct briefings and area meetings and collaborate across departments

🎯 Requirements

• Bachelor's degree • Five (5) years of pharmacy experience in claims operations • Four (4) or more years of experience in compliance, risk management, and/or managed care • 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 • Knowledge of healthcare industry regulations • Knowledge of PBM (Pharmacy Benefit Manager) operations • Ability to interpret and translate guidance for various audiences in a highly matrixed setting • Highly effective communication and ability to influence decisions and build stakeholder alignment • PharmD, Juris Doctorate, or master's degree preferred • Certification in healthcare compliance (CHC, CCEP) or similar preferred • Minimum 25 Mbps download and 10 Mbps upload internet service for home or hybrid work • Dedicated workspace without ongoing interruptions to protect PHI/HIPAA information • Ability to work Monday–Friday, 8:30am–5:00pm EST with some flexibility • Up to 5% travel may be required, including occasional travel outside the state of residence

🏖️ Benefits

• Bonus incentive plan based on company and/or individual performance • Medical benefits • Dental benefits • Vision benefits • 401(k) retirement savings plan • Paid time off • Company holidays • Personal holidays • Paid parental leave • Paid caregiver leave • Short-term disability • Long-term disability • Life insurance • Remote work arrangement • Optional hybrid home/office arrangement for candidates residing in and around Louisville, KY • Up to 5% travel support for regulatory audits and occasional travel for training or meetings