Senior Compliance Professional, Pharmacy

🔥 1 minute ago

🇺🇸 United States – Remote

💵 $86.3k - $118.7k / 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 adherence to government regulations and requirements • Analyze business requirements, conduct research and provide regulatory interpretation to advise internal business units and external business partners • Develop and maintain key relationships with Humana operational leaders and external business partners • Develop and implement monitoring and auditing plans for business processes • Oversee pharmacy compliance for CMS Program Audit focused areas • Cultivate relationships with key partners to ensure compliance alignment on strategic initiatives • Conduct risk assessments and perform auditing and monitoring activities • Develop and track compliance metrics to help monitor and detect potential compliance issues • Present findings of monitoring and auditing efforts to business partners and Enterprise Compliance leaders • Support resolution of CMS inquiries

🎯 Requirements

• Three (3) or more years of experience in pharmacy claims processing and/or pharmacy claims research • Two (2) or more years of experience in health plan compliance or health plan operations • Experience in pharmacy Coverage Determinations for Medicare Part D and/or Organization Determinations for Medicare Part B drugs • Experience creating and utilizing PivotTables, VLOOKUPs, and other Excel functions to analyze, research, and validate claims data • Experience working with regulatory agencies, including CMS and/or state departments of health insurance • Knowledge of PBM (Pharmacy Benefit Manager) operations • Knowledgeable in process improvement and metrics development • Strong communication skills to lead meetings and communicate with business partners • Proven ability to work independently, manage time effectively, and deliver results with minimal supervision.

🏖️ Benefits

• Medical, dental and vision benefits • 401(k) retirement savings plan • Paid time off, including paid time off, company and personal holidays • Paid parental and caregiver leave • Short-term and long-term disability • Life insurance • Competitive benefits that support whole-person well-being