Note: The job is a remote job and is open to candidates in USA. Healthfirst is a not-for-profit health insurer serving members across New York with a range of healthcare plans. The Senior Pharmacy Compliance Reporting Analyst will support pharmacy compliance and regulatory operations by analyzing risks, overseeing delegated pharmacy vendors, managing Medication Therapy Management reporting, and developing automated analytics and reporting solutions.
Responsibilities
- Promote compliance by analyzing, identifying, and addressing risks to regulatory requirements
- Collaborate with other departments to drive implementation, execution and monitoring of regulatory/compliance strategies and expectations for Pharmacy Operations
- Support the Director of Pharmacy Operations to ensure the Pharmacy Benefit Manager (PBM) and other pharmacy delegated vendors adhere to federal and state regulations
- Run the monthly identification of members for the Medication Therapy Management (MTM) program, support the regulatory components of MTM, and ensuring accurate and timely reporting to support outreaches and drive success in the measure
- Ensure the integrity of the data used for day-to day operations and develop program insights and analytic tools
- Enhance and automate compliance reporting solutions, including data collection, validation, aggregation, governance, and reporting
- Develop a robust analytical function for risk detection, profiling, and mitigation. Perform analysis of data to solve complex issues utilizing advanced statistical techniques and analysis
- Develop process to identify and target enrollees for enrollment in the plan's medication therapy management program (MTM) on a monthly basis
- Support additional data requests for MTM outreach as needed. Assist with the evaluation of monitoring approvals, rejections, and timeliness of claims to detect and correct errors
- Perform oversight of language, content, and timeliness of enrollee/provider/pharmacy communications in accordance with regulatory expectations including, but not limited to, communications related to OIG/OMIG provider exclusion list, CMS preclusion list, formulary changes. Coordinate with internal stakeholders and PBM to accommodate non-binary gender identities
- Represent the department to provide all requests and requirements to comply with Transparency in Coverage Rule
- Participate in internal and external audit activities
- Deliver ad-hoc reporting solutions to identify compliance and operational inefficiencies
Skills
- Employer will accept a bachelor's degree in computer science, information science, electrical engineering, or related field and 5 years of experience performing data management and analytics for managed care operations or as a pharmacy benefit manager
- 5 years of experience gathering, analyzing and communicating complex analytical business requirements to diverse audiences, including technical and non-technical stakeholders across different teams and departments
- 5 years of experience developing and utilizing reports and dashboards to analyze and measure performance of products, including translating data insights into actionable business strategies
- 5 years of experience using business intelligence/reporting tools, including Base SAS, SAS EG, Tableau, Aginity Workbench, SQL Server, and Management Studio, to perform advanced statistical analysis, create interactive visualizations, manage databases, automate processes, and ensure data integrity
- 5 years of experience managing multiple concurrent projects supporting various teams, including Finance, Benefits, Utilization Management, Regulatory and Compliance, and Specialty Pharmacy
- 5 years of experience writing scalable, maintainable, well-documented, and supportable code, adhering to best practices to facilitate ongoing system support and enhancements
Benefits
- Medical, dental and vision coverage
- Incentive and recognition programs
- Life insurance
- 401k contributions (all benefits are subject to eligibility requirements)
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