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    Senior Pharmacy Compliance Coordinator - Philadelphia, United States - Blue Cross and Blue Shield Association

    Blue Cross and Blue Shield Association
    Blue Cross and Blue Shield Association Philadelphia, United States

    3 weeks ago

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    Description
    Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together we will achieve our mission to enhance the health and well-being of the people and communities we serve.


    The Senior Pharmacy Compliance Coordinator is responsible for working with and supplying direction to internal partners and external vendors to ensure issues are resolved.

    The direction is based on an understanding of state and federal laws as they apply to Pharmacy Services.

    In addition, the Senior Pharmacy Compliance Coordinator is responsible for managing multiple issue tracking grids through facilitation of meetings and providing direction to cross functional teams.


    Key Responsibilities:

    • Responsible for cross functional issue management for Medicare and Commercial grids and leads meetings.
    o Lead bi-weekly meetings with cross-functional teams to resolve issues.


    o Compliance oversight of issues ensuring documentation aligns with resolution and process improvements to ensure compliance with State and Federal laws.

    o Facilitates external meetings and provides direction towards issue resolution.


    • Supports Management Team with cross functional responsibilities.
    o Represents Managers at meetings as needed.

    o Ensures follow ups are completed as needed.

    o Responsible for Pharmacy Services Compliance Management escalation grid.

    § Maintains grid which tracks all items the Pharmacy Compliance Management Team is monitoring.

    § Facilitate completion of issues by coordinating and leading meetings and bringing updates as needed.

    § On behalf of management team responsible to follow up with next steps and provide direction for issue resolution.


    • Leads External PBM Escalation issues to ensures timely closure.
    o External vendor oversight lead for first level escalations.

    o Maintains the PBM escalation grid.

    o Leads the PBM escalation meeting.

    § Facilitate completion of issues by coordinating and leading meetings and bringing updates as needed.

    § On behalf of management team responsible to follow up with next steps and provide direction for issue resolution.


    • Performs initial assessment of CMS regulations and leads efforts between applicable business owners (Clinical, Compliance, Product, PBM and RPM).


    o Completes an initial review of CMS regulations looping in RPM as needed and coordinates with business owners to obtain responses and evidence of compliance.

    o Enhanced the CMS regulation task from just updating the internal tracking tool.

    o Leads efforts between Clinical, Compliance, PBM and RPM for Medicare and ACA.

    o Participates in bi-weekly meetings with RPM and a separate meeting with the PBM.


    • Moved from audit support to an audit lead.
    o Leads audits as needed.


    • Pharmacy Compliance Lead for Projects
    o Review projects to assess Pharmacy Services impacts and ensure proper stakeholder participation.

    o Attends meetings, completes tasks, provides direction based on internal processes, identifies potential issues and escalations across Pharmacy Services.

    § Lead meetings to educate teams within Pharmacy Services of upcoming projects or potential impacts to current process change.

    § Ensures hand-off of issue from the coordinator to the appropriate Pharmacy Services Team.


    • Identifies and leads process improvements.
    o Works with cross functional teams to identify needed process improvements.

    o Provides direction on behalf of Pharmacy Services to team members.


    • Performance Guarantee (PG) for Medicare, fully insured and self-funded.
    o Responsible for first level dispute process

    § Compare the PBM/IBX PG results.

    § Provide PBM with IBX PG results and financial impact.


    • If additional information is supplied by the PBM meets with business owners to review and does follow up as applicable.

    Qualifications:
    Education & Experience

    Bachelor's degree in business administration or - 7 years' experience in the Healthcare insurance industry.

    Knowledge, & Skills


    • Preferred Pharmacy & Compliance experience
    • Strong written and oral communication skills
    • Project lead experience
    • QA experience
    Equal Employment Opportunity

    Independence Blue Cross is an Equal Opportunity and Affirmative Action Employer.

    All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.

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