Director Compliance_PRX

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At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com.

The Director of Compliance serves as the primary contact for Medicare and Medicaid compliance for PerformRx. The incumbent ensures overall compliance with all Medicare and Medicaid compliance activities and programs; contributes to the development, implementation, and maintenance of system-wide compliance programs; policies, and procedures; and promotes an awareness and understanding of positive ethical and moral principles consistent with the mission, commitment, and core values of the organization and those required by federal and state law.; The Director of Compliance reports to the AmeriHealth Caritas Family of Companies' Corporate Compliance and Privacy Officer.;

As an essential function, the incumbent is responsible for complying with the organization’s Corporate Compliance Program as it applies to the individual job duties, the department, and the organization.

The Director will exercise due diligence to detect, prevent and report unlawful and/or unethical conduct, as well as fraud, waste and abuse, by fellow co-workers, professional affiliates, and/or agents.

Specific;Responsibilities;include:

• Serves as the primary compliance contact and the person responsible for ensuring overall compliance with Medicare and Medicaid compliance requirements relating to PBM program.
• Coordinates implementation of system-wide programs, policies, and procedures to ensure system compliance with applicable federal and state laws and regulations.
• Coordinates written policies and procedures that set up standards for compliance; giving specific guidance to management, professional staff, and individual departments as appropriate.
• Develops, implements, and maintains a system for efficient operations of the Compliance Department that includes a; communication tracking process for compliance program documentation and compliance committee projects and interaction.
• Responsible for organizational compliance with CMS and State transmittals, HPMS notices, CMS and State required applications and submissions as they relate to the PBM program. Maintains HPMS information, as appropriate. Includes maintenance of a process to timely inform stakeholders about applicable procedural changes, regulatory changes, and contractual changes.
• Develops, implements, and maintains a system for confidential reporting and investigation of compliance concerns with an appropriate response process. Includes creation of an environment that facilitates freedom to report concerns or incidents of wrongdoing without fear of retaliation; and coordination of an external reporting system (toll free hot line), coordinating with Corporate Compliance when indicated.
• Coordinates with legal counsel in response to identified compliance questions, concerns, or federal/state inquires or investigations.
• Maintains an “open door” policy and directs efforts to communicate compliance programs, including written materials and training programs designed specifically to promote understanding of compliance issues, laws and regulations, and consequences of non-compliance.
• In coordination with internal legal consultants; maintains awareness of laws and regulations, keeping abreast of current changes that may affect health care systems. Utilizes personal initiative, seminars, training programs, peer contact, and various industry information sources (i.e., Internet sites, newsletters, etc.).
• Maintains a consistent management reporting process that provides the system with timely and relevant information on all aspects of compliance issues.
• Reviews and investigates reported issues, concerns, or questions relative to compliance matters. Provides consultative leadership and support to all entities as appropriate. Includes close coordination with the Director of Human Resources in connection with consistent enforcement of disciplinary policies and otherwise; as well as and interaction with all levels of management throughout the organization.
• Coordinates with Program Integrity to develop and implement systems and procedures to prevent and detect fraud, waste, and abuse in connection with PBM and pharmacy services.
• Coordinates the development, implementation, and maintenance of audit controls and measurements for internal and external processes, ensuring correct processes are in place for accurate, complete, and compliant programs across the system – including subcontractors and/or First Tier, Downstream and Related entities (FDRs)/Vendors. Works cross-functionally to ensure identified non-compliance is remediated.
• Coordinate fulfillment of all Federal (CMS), State and other regulatory audits.
• Chairs the Compliance Committee and provides leadership for the compliance function and staff.
• In coordination with the Compliance Committee, informs the compliance program to improve its effectiveness or in response to changing organizational needs or new/revised regulations, policies, and guidelines.
• Communicates to and works collaboratively with the Chief Compliance Officer, President of PerformRx, the PerformRx Board of Directors, and in-house Legal counsel. Prepares monthly and/or quarterly compliance summaries for the organizations leadership, as outlined above, as well as the Compliance Committee.
  
  

Education/Experience:

• 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 Pharmacy Benefit Management (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
• Places a high value on ethical standards and treating others with dignity and respect
  
  

Diversity, Equity, and Inclusion

At Amerihealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

We keep our associates happy so they can focus on keeping our members healthy.

Our Comprehensive Benefits Package

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