Director, Pharmacy Compliance & Oversight

Role and Responsibility:
•Oversee and direct Medicare, Medicaid, and Marketplace related products working with our Pharmacy Innovation Partner assuring all activities are compliant with CMS and State regulations
•Responsible for maintaining strong oversight over CareSource’s Pharmacy Innovation Partner relationship to include contract compliance monitoring (including pricing), performance guarantee maintenance, regulatory oversight, oversight and monitoring of alldelegated functions performed by PBM, coordination and facilitation of quarterly reporting and operational meetings; inclusive of focus on Medicare program oversight
•Negotiate, coordinate and direct the pharmacy negotiation process and tactics with outside suppliers, legal counsel, business managers, and strategic sourcing departments
•Lead processes, policies and procedures to ensure compliance with corporate, state, federal, regulatory, NCQA and URAC requirements
•Management of functional SG&A budget and effective management of capital and human resources across assigned areas
•Integrate and leverage relationships with other areas within CareSource, such as Care Management, Member Services, Marketing/Communications, HEDIS Operations, etc.
•Drives Best-In-Class performance for compliance, cost and Stars Ratings
•Develop executive dashboards tracking all KPIs for assigned areas
•Lead the pharmacy operation components related to our Pharmacy Innovation Partner functions within CareSource for both clinical and operational areas
•Collaborate with Directors within the pharmacy team to bring a consolidated message to our PBM
•Participate in employee evaluations and conduct disciplinary action, as needed
•Develop and maintain excellent working relationships with all internal and external constituencies
•Represent Pharmacy on company-wide committees relating to operational, regulatory and financial oversight
•Determine minimum workflow standards
•Contribute to determining “as is” and “to be” operational and staffing needs of the Pharmacy department to meet standards as required by state regulations
•Evaluate current policies, procedures and practices for accomplishing the assigned work functions/objectives; develop and implement new or improved procedures for operational effectiveness and efficiency
•Perform any other job related instructions, as requested

Education / Experience:
•Bachelor’s degree in a relevant field or equivalent years of relevant work experience is required
•A minimum of seven (7) years of leadership/management experience of clinical and non-clinical staff is required
•Minimum of seven (7) years of compliance / oversight experience with Medicare and Medicaid pharmacy rules and regulations is required
•Minimum of three (3) years of recent contracting, quality improvement and management experience in a healthcare environment, preferably managed care is required
•Pharmacy Benefit Management operations experience is preferred

Required Competencies / Knowledge / Skills:
•Intermediate computer skills including Microsoft Word, PowerPoint and Excel
•Exceptional interpersonal skills with a high degree of personal integrity, compassion and savvy to foster a collaborative and partnership-based approach to achieve company initiatives, with both internal business partners, as well as, external companies
•Ability to manage multiple complex and competing priorities with strong organizational and relationship building skills
•Demonstrated skill leading enterprise-wide initiatives and changes
•Strong operational leadership skills
•Strong needs analysis and planning skills
•Strong people management skills
•Strong budgeting and financial skills
•Strong external and internal communications
•Thorough knowledge of pharmaceutical care and pharmacy benefit management practices
•Strong customer service skills
•Strong project management skills
•Knowledge of retail pharmacy operations
•Knowledge of pharmaceutical regulations
•Knowledge of pharmaceutical industry and its trends
•Ability to work independently and within a team environment
•Strong attention to detail, including work plan development and execution skills
•Knowledge of the healthcare field overall
•Negotiation skills/experience
•Strong communications skills (written and oral)
•Ability to critically think, make decisions and problem solve
•Strong computer skills and good analytical and mathematical skills

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