ROLE SUMMARY

• Reporting to the Pharmacy Compliance Director, this position will be responsible for leading Provider and Supplier compliance to Medicaid and Medicare requirements, and other Pharmacy Compliance programs managing an effective program of healthcare compliance. This role will be an integral part of the Pharmacy Compliance team supporting all ESI Pharmacies, including their U.S. subsidiaries, and affiliated products under Evernorth Health Services. The ideal candidate will have a strategic mindset and have the ability to drive change and influence others, as well have broad based knowledge of pharmacy operations and government payor programs, and be able to identify compliance impacts and risks.

ROLE RESPONSIBILITIES

Key Duties:

• Manage a team of compliance professionals accountable for government payor compliance of the ESI pharmacies.
• Compliance with government payor requirements for ESI Pharmacy Providers and Suppliers.
• Manages a change control process for the intake, communication, business compliance analysis, and repository of government payor requirements (e.g., State Medicaid and CMS requirements).
• Understanding the impact of other government payor Provider and Supplier requirements (e.g., State Medicaid and CMS requirements) as it pertains to limitation on pharmacy and medical plan benefit coverage and services.
• Research and respond to pharmacy and government payer compliance questions in consultation with Legal and Compliance stakeholders.

Compliance Program Duties:

• Coordination and development of auditing and monitoring plans focusing on areas of high compliance risk within the pharmacy government payor space.
• Creation of dashboards and status updates which communicate audit and monitoring results, trends, and summarize risk remediation activity.
• Develops high quality and effective presentations and reports for senior management, including Board / Committee reports, covering the compliance landscape.
• Assist peers in managing and prioritizing workload assignments across multiple priorities to achieve optimal compliance departmental performance.
• Manages and maintains team’s Compliance Work plan.
• Participate in assessment of risk for ESI Pharmacies.
• Lead, participate and facilitate accessible knowledge and guidance for business stakeholders including Compliance committees and other delivery mechanisms as needed.
• Update, revise, and maintain applicable departmental policies and procedures, and support the review of policies and documents for supported business units.
• Training development and support of business stakeholders on applicable compliance topics.

Leadership Duties:

• Strong team leadership of core responsibilities while developing a diverse, nimble, and knowledge team.
• Takes ownership and accountability in own work responsibilities.
• Demonstrates dedication, passion, and ethics towards department duty.
• Development and management of technology and automation used to support Pharmacy Compliance program activities (Service Now, SharePoint, etc.).
• Develops and maintains a strong working knowledge of Evernorth’s companies, products, licenses and business segments.

Soft skills:

• Excellent oral, written presentation and communication skills
• Ability to lead and influence in a matrixed environment is critical
• Proven track record of delivering results of high quality and sustainability
• Strong problem solving and root cause identification skills
• Strong business acumen, with proven ability to leverage knowledge base to quickly come up to speed in new business areas and new types of projects
• Proven ability to develop strong working relationships and establish a high level of credibility across functional and lines of business and organizational levels
• Adapts to ambiguous or unfamiliar terrains; Strong strategic thinker
• Ability to lead teams through growth, change, and development

POSITION REQUIREMENTS / QUALIFICATIONS

• Bachelor’s degree or equivalent training and mastery required; Registered Pharmacist is required for this role.
• Minimum of 6 -8 years’ experience in pharmacy practice focused in specialty, home infusion and mail order pharmacy services needed.
• Minimum of 6-8 years’ experience in a compliance or regulatory role, with a focus on direct health care experience involving knowledge of government payor and regulatory requirements for pharmacy providers and suppliers, strongly preferred but not required.
• *Government payor experience, in particular Medicaid required
• Successful management experience in highly matrixed environment with proven results.
• Excellent written and oral communication skills.
• Strong planning/organizing/prioritizing skills with ability to meet changing priorities and critical deadlines.
• Expertise in the use and application of the Microsoft suite of programs including Word, Excel, Outlook, and PowerPoint.
• Exceptional integrity, critical thinking, and leadership stature.
• Takes personal accountability for team and organizational results.
• Prior experience leading a cross functional team.