Job description
LE0006 MSO of Puerto Rico, LLC
It's fun to work in a company where people truly BELIEVE in what they're doing!
We're committed to bringing passion and customer focus to the business.
BUSINESS UNIT: MSO of Puerto Rico
DEPARTMENT: Pharmacy Services
POSITION: Analyst- Pharmacy Regulatory Oversight
POSITION DESCRIPTION
The Pharmacy Regulatory Oversight Analyst is responsible for monitoring and assessing the Pharmacy operational, regulatory and five stars requirements to ensure high quality standards and conformance to the Centers for Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), PR Healthcare Insurance Administration (ASES by its Spanish Acronym) and local state requirements are being met by:
- Leading the audit activities and engaging with cross functional teams to ensure all related CMS activities and internal monitoring are performed and delivered on time in accordance with the corresponding regulatory requirements.
- Managing all regulatory, stars and compliance findings, which includes coordinating with Plan’s and PBM operational areas to develop effective Corrective Action Plans (CAP’s).
- Evaluating current policies and procedures against guidelines requirements to identify gaps and propose system and process improvements.
- Ensuring system enhancements are performed according to business needs and requirements while meeting regulatory requirements.
- Performing vendor oversight for delegated entities
- Evaluating all CMS memos and downstream impact in the Pharmacy processes.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Support CMS Audits, NCQA accreditation and any other delegated/internal audit activities impacting the Pharmacy department. Support CMS audits and NCQA accreditation which includes and not limited to:
Gather required universes and evidence among others
Lead, Coordinate, evaluate and document CMS Audit samples in any related internal and external audits.
Document internal and external audit results to the Pharmacy Management Team and propose and implement corrective actions, as needed.
Assess, distribute and update the Pharmacy department’s policies and procedures in order to identify any process gaps, recommend process improvements and implement accordingly.
Lead the internal and external Pharmacy Corrective Action Plans (CAPs) to ensure successful completion is accomplished. Document, track and manage associated statement of work’s corrective action plans (CAP) and provide necessary follow-ups. Ensure deadlines are met accordingly. Maintain an accumulated log of systemic issues identified, coordinate with the impacted owners of the CAPs to resolve and mitigate any future instances.
Oversee the Data Validation Audit (DVA) to ensure all required documentation and deadlines are being met according to CMS protocols.
Support the new year’s benefit testing and related policy and procedures updates.
Collaborate with the Pharmacy Oversight team members and other Pharmacy units to ensure critical audits and targeted monitoring are being performed in order to meet overall audit scope.
Manage and update at least yearly and as applicable the Pharmacy Department training log and assure training needs are included in log and executed as agreed.
Communicate/elevate identified unresolved issues to the appropriate supervisor as needed.
Coordinates/advocates resolution of member pharmacy issues, concerns, and grievances.
Perform vendor oversight for delegated entities.
Coordinate and execute the Pharmacy Internal Audit Plan including but not limited to the following procedures:
Medicare Plan Finder
FIR/ Nx Rejects
Marketing Materials
TrOOP
PDE
Rejects Monitoring
MTM Program
Coverage/ Organizational Determinations
Quality Process
Formulary Administration
Overutilization/ Opioids
P&T Committee
Claims Processing
Provider Call Center
Recovery Process
Vendor Oversight
Create, update and maintain the Pharmacy Corrective Action Plan/ Workplans Log and manage through completion its execution according to established timelines.
Create, update and maintain the Pharmacy Compliance Issue Log and manage through item’s resolution according to established timelines.
Lead and coordinate weekly meetings with the Pharmacy department and the Compliance organization.
Monitor Pharmacy workbasket activities.
Coordinate quality and compliance related tasks within the Pharmacy Oversight team.
Provide and maintain visibility of Stars and Department’s Compliance metrics.
Perform other duties as designated by Pharmacy Support or Oversight Supervisor.
EDUCATION AND EXPERIENCE
- Bachelors’ Degree or experience equivalent to 4 years in healthcare related job. Experience on compliance or audit process is a plus. Evidence of an advanced level of mathematical knowledge, and good communication, interpersonal, problem‑solving, orientation to detail, and strive for excellence skills
- Medicare and Medicaid experience
- Knowledge of the Pharmacy Adjudication System
- Knowledge of health plan pharmacy benefit administration
GENERAL ABILITIES AND KNOWLEDGE
- Basic business intelligence knowledge and techniques
- Ability to complete thorough comparative analysis and conclusions
- Object-oriented analysis
- Computer knowledge
- Familiar with basic concepts of project management and business analysis
- Ability to respond to a high volume of work and maintain a polite and professional manner at all times. Must demonstrate positive attitude. Strong interpersonal skills.
- Able to function with frequent interruptions
- Ability to prioritize workloads for maximum efficiency
- Able to sit for extended periods of time without compromising work performance
- Team Work: ability to work in a team environment to provide solutions to problems
- Can work flexible schedules including night shifts, weekends, and holidays
- Business modeling techniques
- Technical writing
LANGUAGE SKILLS
Fully Bilingual (English and Spanish). Read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents. Respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community. Write speeches and articles for publication that conform to prescribed style and format. Effectively present information to top management, public groups, and/or boards of directors.
MATHEMATICAL SKILLS
Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
REASONING ABILITY
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
PHYSICAL AND MENTAL DEMANDS
Working on computer and telephone for long periods of time; ability to effectively utilize office telephone equipment; repetitive motion using fingers and forearms in data entry, manual dexterity to access filing system, use fax and copy machines. This position requires that weight be lifted or force be exerted up to 10 pounds.
ENVIROMENT AND WORKING CONDITIONS
Normal office environment. The noise is typically moderate.
If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!
offroadmanagementgroup.com is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, offroadmanagementgroup.com provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, offroadmanagementgroup.com is the ideal place to find your next job.