Director Compliance_PRX

AmeriHealth Caritas - Newtown Square, PA

Full-time - Senior

Remote - Newtown Square, PA

Insurance Carriers and Related Activities

About the position

The Director of Compliance at AmeriHealth Caritas is responsible for overseeing compliance with Medicare and Medicaid regulations within the Pharmacy Benefit Management (PBM) program. This role involves developing, implementing, and maintaining compliance programs, policies, and procedures, while promoting ethical standards and compliance awareness throughout the organization. The Director serves as the primary contact for compliance issues and ensures adherence to federal and state laws, contributing to the overall mission of delivering quality healthcare solutions.

Responsibilities

• Serve as the primary compliance contact for Medicare and Medicaid compliance requirements relating to the PBM program.
• Coordinate implementation of system-wide compliance programs, policies, and procedures.
• Develop and maintain a system for efficient operations of the Compliance Department, including communication tracking for compliance documentation.
• Ensure organizational compliance with CMS and State transmittals, notices, and required applications related to the PBM program.
• Maintain a process for timely informing stakeholders about procedural, regulatory, and contractual changes.
• Develop a system for confidential reporting and investigation of compliance concerns, ensuring a safe reporting environment.
• Coordinate with legal counsel regarding compliance questions and federal/state inquiries.
• Maintain awareness of laws and regulations affecting healthcare systems and communicate compliance programs effectively.
• Review and investigate reported compliance issues and provide consultative leadership to all entities.
• Coordinate with Program Integrity to prevent and detect fraud, waste, and abuse in PBM and pharmacy services.
• Chair the Compliance Committee and provide leadership for the compliance function and staff.

Requirements

• Bachelor's Degree required (Healthcare and/or Regulatory related); Master's degree preferred.
• Current/recent leadership and Compliance and/or Regulatory experience at a Pharmacy Benefit Management (PBM) organization required.
• Minimum of five (5) years of management experience in Medicare Managed Care and/or Medicaid Managed Care in a PBM environment is required.
• Clinical Pharmacy, Pharmacy Technician and/or Pharmacy Operations subject-matter expertise preferred.
• National Pharmacy Technician Certification (ExCPT, NCC or PTCB) is a plus.
• Extensive healthcare software and word processing experience.
• Strong leadership, interpersonal, and problem-solving skills.
• Demonstrates personal traits of a high level of integrity, team orientation, professionalism, and trustworthiness.

Nice-to-haves

• Experience in compliance within the healthcare sector.
• Knowledge of ethical standards and compliance regulations.

Benefits

• Health insurance coverage for you and your dependents on Day 1
• Paid holidays
• Paid time off including holidays and volunteer events
• Tuition reimbursement
• 401(k)
• Flexible work solutions including remote options, hybrid work schedules
• Competitive pay