Senior Compliance Professional PBM amp Pharmacy

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Job Information
Humana
Senior Compliance Professional (PBM & Pharmacy)
in
Riverton
Wyoming
Description
The Senior Compliance Professional ensures compliance with governmental requirements. The Senior Compliance Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.
Responsibilities
The Senior Compliance Professional develops and implements compliance policies and procedures. Researches compliance issues and recommends changes that assure compliance with regulatory and contract obligations. Coordinates business partner engagement with regulators, and compliance with corrective action plans, as needed. Provides compliance guidance, direction and compliance risk assessment to assigned business partners, conducts periodic compliance reviews of business partner operations. Monitors metrics and other oversight tools that indicate business area compliance. Recommends new measures of compliance performance. Works with systems to track issues and corrective actions, when needed. Begins to influence department's strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.
The Senior Compliance Professional's primary focus will be to develop and implement a plan to monitor and audit business processes to prevent, detect, and resolve compliance issues to help ensure an effective compliance program for Pharmacy Benefits and pharmacy benefit management (PBM) administration.
Key responsibilities may include:
Research, understand and apply laws, regulations, and regulatory guidance for Pharmacy Benefits and PBM administration business compliance issues.
Serve as the subject matter expert on Pharmacy Benefits and PBM administration compliance issues.
Develop audit methodology and perform auditing and monitoring activity to prevent and detect issues of noncompliance and provide guidance on remedial actions to strengthen compliance controls and ensure compliance with state and federal laws and regulations.
Analyze business requirements and complex issues, conduct research, and provide regulatory guidance to business partners, law, and risk management associates and leaders with regard to Pharmacy Benefits and PBM administration compliance issues.
Develop and track compliance metrics to help monitor and detect potential compliance issues.
Partner with Audit Coordination team members on regulatory outreach.
Serve as the Regulatory Compliance subject matter expert during audits and exams.
Lead program audit preparation and activity and perform oversight of business audit preparation to ensure timely, accurate and complete submission of required data and documentation to regulators.
Present findings of monitoring and auditing efforts to business partners and Enterprise Compliance leaders and track issues to ensure appropriate and timely remediation.
Lead and participate on projects and committees, providing compliance guidance and direction.
Provide back-up and support to other Enterprise Compliance team members and perform other duties, as needed.
Required Qualifications
Bachelor's degree
5 years of experience in regulatory, law, compliance, audit, consulting and/or risk management.
Demonstrated ability to run large -scale, highly-visible programs with responsibility for multiple project teams
High level of emotional intelligence
Knowledge/understanding of laws and regulations governed by the Department of Insurance and other regulatory agencies
Strong communication skills with the ability to influence effectively
Comprehensive knowledge of MS Word, Power Point, Excel
Excellent communication skills, both oral and written
Preferred Qualifications
J.D. or other graduate degree
Previous Pharmacy or PBM experience
Knowledge of the healthcare insurance industry
Experience interacting with governmental agencies
Experience with metrics and reporting
Network and Credentialing experience
Additional Information
For this job, associates are required to be fully COVID vaccinated or undergo weekly COVID testing and wear a face covering while at work. The weekly testing will need to be done through an approved Humana vendor, and unvaccinated associates should follow all social distancing and masking protocols if they are required to come into a Humana facility or work outside of their home. We are a healthcare company committed to putting health and safety first for our members, patients, associates, and the communities we serve.
If progressed to offer, you will be required to:
Provide proof of full vaccination OR
Commit to weekly testing, following all CDC protocols, OR
Provide documentation for a medical or religious exemption consideration.
This policy will not supersede state or local laws. Requests for these exemptions should be submitted at least 2 weeks prior to your scheduled first day of work.
Scheduled Weekly Hours
40
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our ****

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