Pharmacy Regulatory Program Manager

The Pharmacy Regulatory Program Manager serves as the subject matter expert for Centers for Medicare & Medicaid Services (CMS) regulatory guidance related to the Medicare Advantage Part D Pharmacy Coverage Determination processes and all other CMS rules and guidance that impact drug coverage for Medicare or Commercial plans. This position ensures all related policies and procedures for both lines of business are updated timely and accurately to comply with federal and state regulations, quality accreditation standards, and company policies.

This Program Manager works closely with the Plan’s Compliance Department to ensure accuracy of the audit universes and other regulatory reporting requirement. The role is responsible for relaying any regulatory updates or changes to VIVA HEALTH’S Pharmacy team and creating training materials. This position will actively participate in regulatory audits.

Work Schedule

Hybrid schedule with regular work onsite at the VIVA HEALTH corporate office and some work-from-home opportunities.

Why VIVA HEALTH?

VIVA HEALTH, part of the renowned University of Alabama at Birmingham (UAB) Health System, is a health maintenance organization providing quality, accessible health care. Our employees are a part of the communities they serve and proudly partner with members on their healthcare journeys.

VIVA HEALTH has been recognized by Centers for Medicare & Medicaid Services (CMS) as a high-performing health plan and has been repeatedly ranked as one of the nation's Best Places to Work by Modern Healthcare.

Benefits

• Comprehensive Health, Vision, and Dental Coverage
• 401(k) Savings Plan with company match and immediate vesting
• Paid Time Off (PTO)
• 9 Paid Holidays annually plus a Floating Holiday to use as you choose
• Tuition Assistance
• Flexible Spending Accounts
• Healthcare Reimbursement Account
• Paid Parental Leave
• Community Service Time Off
• Life Insurance and Disability Coverage
• Employee Wellness Program
• Training and Development Programs to develop new skills and reach career goals
• Employee Assistance Program

See more about the benefits of working at Viva Health -

Key Responsibilities

• Maintain current knowledge of Medicare and Commercial regulatory and sub-regulatory guidance related to areas of responsibility and interpret/ communicate impact on work processes to stakeholders.
• Responsible for the accuracy and preparation of Part D Reporting requirements to include coverage determinations, redeterminations, coverage determination reopenings, redetermination reopenings, DUR, and Part C reporting requirements to include organization determinations and organization determination reopenings.
• Responsible for the accuracy and preparation of coverage determination, redetermination, organization determination, and other (i.e.: formulary, formulary disruption, annual opioid education) member and provider communications to be maintained according to CMS regulatory guidance and VIVA HEALTH’S internal compliance guidelines.
• Responsible for reporting of Prescription Drug Events processing related to the application of the Part D and Part B benefit related processes. (Example: to GLP-1 medications, insulin medications, and immunosuppressant medications and any other drug review categories.)
• Prepare and maintain policies, procedures, and training documents involving regulatory/accreditation oversight related to the Clinical and Operational processes for pharmacists and technicians.
• Maintain supporting databases/documentation systems in compliance with regulatory updates by providing written change specifications to the Information Systems department, collaborating on system updates, and conducting user acceptance testing.
• Serve as the subject matter expert to the Plan’s Compliance Officer and regulatory auditors related to the coverage determination process.
• Assist with the maintenance, development, and coordination of the Plan’s Quality Assurance (QA) processes regarding Part D coverage determinations.
• Responsible for the accuracy and review of the Plan’s regulatory universes as well as conducting and providing feedback to management.
• Work closely with the Pharmacy Operations and Clinical Leadership Team to ensure a common understanding of all regulatory programs and interventions to ensure proper communication and help manage tight deadlines.

REQUIRED:

• Bachelor's Degree
• 2 years’ experience in a position requiring interpreting, applying, and communicating regulatory guidance
• Experience working with databases and generating reporting from databases
• Proficient in the Microsoft Office suite of products including Excel, Word, and PowerPoint
• Excellent customer service skills and experience demonstrated through oral and written communication

PREFERRED:

• Advanced Graduate Degree in a healthcare related field, Business, or Law
• 3 years’ experience in Medicare Advantage/Part D, Medicare, Drug Benefit Administration, or auditing
• Experience with advanced Excel, SQL, Crystal Reporting
• CISA or CIA; Health care professional license (RN, Pharmacist)
• Experience in interpreting governmental regulations and applying them to business operations
• Experience in a liaison role between a business unit and information technology/services
• Technical writing including policy and procedures
• Experience in an auditing or quality assurance role