Healthfirst

The Senior Regulatory Specialist – Pharmacy is responsible for promoting compliance with regulatory requirements within Healthfirst's Pharmacy and Dental departments and/or delegated vendors. Compliance is promoted by ensuring regulatory updates are evaluated and properly implemented, along with performing monitoring to evaluate compliance with regulatory requirements required by Centers for Medicare and Medicaid Services (CMS) and State Department of Health (DOH) regulations, and business requirements. The role also entails supporting the maintenance and oversight of the Restricted Recipient Program (RRP).

Duties & Responsibilities:

• Monitor incoming regulations including those received from Centers for Medicare and Medicaid Services (CMS), State Department of Health (DOH), Office of Medicaid Inspector General (OMIG) and other channels.
• Share regulatory guidance with Pharmacy department and provide support to ensure regulation and impact are understood. Act as a liaison between Pharmacy Department and Regulatory Affairs/Legal when guidance on interpretation is required.
• Provide support to Pharmacy Department related to regulatory implementation efforts including:

• Tracking deliverables to target
• Coordinating meetings and collecting deliverables from business units.
• Capturing action steps
• Communicating to leadership

• Coordinate monthly meetings with the RRP review team and in collaboration with other departments
• Support all RRP committee meetings and be responsible for documenting attendance and monthly meeting minutes
• Data analysis of pharmacy and medical claims data to identify potential candidates for RRP
• Review claims reporting to identify inappropriate fraud, waste, and abuse trends resulting in referral for review by the RRP committee for potential restriction
• Participate in monthly OMIG meetings and subsequently meet with internal stakeholders to review determine actionable items
• Manage and maintain proper documentation of the RRP roster. This includes managing referrals from OMIG, members transitioning into the plan under previous MCO or fee for service (FFS) restriction and ensuring timely reviews of members up for re-restriction are being conducted. Also includes maintaining detailed summary reviews, determinations, and appeals associated with member
• Process new enrollee RRP notices to new members joining the plan with restrictions under a previous MCO or FFS
• Process provider notifications when a provider is designated as a member’s restricted provider.
• Process restriction change requests from members, OMIG, and DOH
• Conduct monthly, quarterly, and annual monitoring for the processes of RRP to reduce compliance risks
• Triage RRP Inbox requests and prioritize tasks based on urgency, importance, and service level agreement (SLA)
• Process Fair Hearing requests within one business day of receipt
• Assist with state audits, with data analysis of pharmacy and medical claims data
• Identify process gaps or process improvements and collaborate with Pharmacy department and other business units to implement process enhancements.
• Creating comprehensive corrective action plans.
• Attend Regulatory, Pharmacy and departmental meetings, as deemed appropriate.
• Additional duties as assigned.

Minimum Qualifications:

• High School Diploma or GED from an accredited institution
• Working knowledge of CMS and state regulatory requirements

 

Preferred Qualifications:

• Bachelor's degree from an accredited institution.
• Knowledge of regulations of Medicaid Services and the New York State Department of Health
• Managed Care experience
• Pharmacy experience

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $83,100 - $120,360

• All Other Locations (within approved locations): $73,400 - $109,225

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

*The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified.