Senior Analyst – Healthcare Compliance

Senior Analyst – Healthcare Compliance

Requirements

• 3+ years of experience in the pharmacy industry with knowledge of standard contract terms and conditions, best practices, and business policies​

Responsibilities

• Make informed decisions by thoroughly reviewing communications distributed by PBMs, processors, health plans, state Medicaid and Medicare, relative to prescription and/or medical claim processing
• Serve as a subject matter expert for both internal and external representatives by researching prescription insurance program requirements, medical billing policies, compliance inquiries, and related issues/complaints, and crafting timely responses
• Demonstrate care by proactively identifying and resolving potential Third-Party operational issues
• Understand the terms of Payer contracts, and NCPDP Standards, to ensure CVS and plan compliance
• Translate, and clarify where needed, payer information and communicate to appropriate internal personnel, field management, and CVS pharmacy locations
• Compose third party articles for the Payer Relations Weekly Update, issue emergency communications via the pharmacy HUB, and post Medicaid related third party program requirements on the Intranet, as necessary
• Foster and maintain a professional effective working relationship with contracted agencies, PBMs, and health plans
• Problem solving point of contact for complaints and inquiries received from payers on behalf of our mutual customers
• Collaborate with payers, internal departments, and field personnel, to implement process improvements for prescription and/or medical claim processing, to ensure program compliance and to enhance store level customer service
• Keep Payer Relations Contracting Directors and/or appropriate management apprised of problematic Payer related issues that may significantly impact prescription processing
• Evaluate third party information to determine if an internal system update is required
• Track plan changes via database, and prepare necessary documentation to facilitate new third-party plan codes and/or updates to existing codes
• Collaborate with appropriate internal Payer Relations team(s) to determine best approach for system updates, when needed
• Focus on the customer by addressing prescription processing escalations received from various internal departments and pharmacy teams
• Contribute to a high-performing team by looking for opportunities to achieve individual and broader team goals, while remaining flexible for changing business needs, to enable supportive, collaborative, and management of challenging work
• Assist with implementation of procedures, policies, and other projects as needed, to develop processes for efficient day to day payer and customer support

Preferred Qualifications

• Knowledge of Pharmacy Benefit Management is a plus
• Bachelor’s Degree preferred
• Demonstrated ability to think strategically, act tactically, and deliver outcomes
• Organized and detail-oriented, with the ability to manage multiple tasks simultaneously and adjust priorities as needed, demonstrating high level of independent judgment and proactivity
• Self-starter with strong interpersonal and leadership skills. Demonstrated ability to effectively influence other business areas in a matrixed complex organization