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CAMBIA HEALTH SOLUTIONS, INC. Pharmacy Ops Oversight in SALT LAKE CTY, Utah

Pharmacy Operations Oversight specialist OR SRRemote within only ID, OR, UT, WAAssists in planning, coordinating, conducting, and reporting on pharmacy operations activities carried out by delegated entities which provide Pharmacy Benefit Management services to Cambia's Medicare Part D, Exchange or commercial portfolio. Specifically, this job performs oversight of vendors' delegated responsibilities which may include: Prescription Drug Event (PDE); Coverage Determinations, Appeals, and Grievances (CDAG); Formulary Administration (FA); Refund and Recovery (RR); and other operations oversight functions as assigned. Supports CMS, state, customer audit initiatives by investigating samples, identifying scenarios of concern, researching claims within the pharmacy system, and evaluating reports with a focus on identifying potential gaps in the existing oversight activities.Responsibilities *Contributes to the development and implementation of oversight, monitoring, and audit plan related to Regence's healthcare providers and other contracted entities. *Partners with internal departments to ensure that the contracts with Regence's healthcare providers and other contracted entities include updated and relevant contractual language. *Requests operations attestations, examines documentation, interviews operations contacts, and performs other procedures necessary to ensure that Regence's healthcare providers and other contracted entities are meeting operations expectations. *Clearly and concisely documents work performed ensuring Regence's service providers and other contracted entities are compliant with applicable CMS or other regulatory requirements. *Develops written findings with respect to non-operations with regulations. *Coordinates operations monitoring efforts with office managers, operations officers, and high-level external entities. *Writes and/or edits formal reports; assesses and communicates identified findings. *Conducts and documents follow-up procedures on findings and reports on the status of corrective action taken. *Conducts special projects and investigations as requested. *Keeps abreast of emerging issues and developments in the health insurance industry especially as it relates to Medicare or the Exchange. Additional Minimum Responsibilities for Pharmacy Operations Oversight Specialist Senior: *Create, maintain, and deliver oversight reports and program updates to compliance teams within the company and attheclient. *Compile executive-level summaries of compliance programs and deliver as needed. *Design oversight programs to achieve desired results, target areas of risk, and mitigate compliance vulnerability for the plans. *Work closely with compliance leadership at the plans at a strategic level to ensure that oversight programs effectively deliver desired results to the client. Minimum Requirements *Demonstrated understanding of practices and requirements related to Medicare Part D and/or Insurance Exchange and Commercial pharmacy products, CMS and State guidance and PBM claim adjudication systems. *Demonstrated ability to translate compliance concepts into practical operational oversight. *Demonstrated proficiency with Microsoft office products including Word, Outlook, PowerPoint, Excel, Access, Visio and Sharepoint. *Experience with business analysis and continuous process improvement. *Demonstrated ability to analyze large amounts of data and handle complex requests. *Demonstrated ability to develop reports and executive summary documents. *Demonstrated knowledge of Pharmacy Claim Analysis and quality practices. *Demonstrated knowledge of pharmacy claims processing systems, particularly RxClaim. *Demonstrated proficiency with either SAS or SQL and Oracle/SQL including ability to write queries based on business need. Additional Minimum Requirements for the Pharmacy Operations Oversight Specialist Senior: *Demonstrated expert understanding of practices and requirements related to Medicare

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