Health Plan Compliance Analyst, Managed Care Pharmacyitle
Under general supervision, assists with the development of the Denver Health Medical Plan, Inc. (DHMP) Medicare, Medicaid and CHP+ Programs to ensure compliance with all Federal and State–level regulatory requirements. Leads and provides expert technical assistance to highly visible, sensitive, and multifaceted compliance initiatives. Provides assistance in setting strategic direction of projects, developing project plans, analytic support services and technical expertise to a board array of Medicare, Medicaid and CHP+ issues. This position will interact with all levels of management and employees, plan members, external consultants and Federal and State representatives.
*Shift: Monday-Friday, 8:00am-5:00pm
Reports on standard pharmacy data metrics required for monitoring of the Pharmacy program and regulatory compliance. Assists in data transfer between health plan departments and vendors as well as data updates and submissions required to maintain compliance with state and federal regulations. Effectively communicates Medicare Regulations and Rules as related to Pharmacy to all employees through education and training programs. Provides advice and interpretation of Medicare Regulations and Rules related to DHMP related policies. Ensures appropriate program and operations processes are in place, identify opportunities for process improvements through analyses of patterns, forms, and knowledge of the compliance program. Monitors daily new and existing regulations, guidelines and regulatory requirements. Communicates proposed and approved regulatory changes to all impacted areas and assist with implementation of appropriate changes. Assists with the development of daily, weekly, monthly and quarterly reports as required by the Pharmacy team for clinical programs. Plans, organizes and assists in comprehensive investigations of suspected violations, external and internal audits of the organizations contracts. Assists in the execution of all audits and technical assistance letters and reviews from CMS or other agencies. Critically analyzes situations, data and information; develops and pose probing questions. Compiles report summaries as needed of investigations and findings of any violations. Writes, maintains and updates as needed pharmacy technician training documents and user access to Pharmacy technical systems. Other duties as assigned.
Knowledge, Skills & Abilities:
Critical thinking, strong written and verbal communication skills, and the ability to effectively interact within a team. Ability to develop data requirements and work with teams and groups to extract, organize and analyze data and trends. Ability to define problems: collect data, establish facts and draw valid conclusions to implement solutions. Ability to effectively present information and respond to questions from management and others. Ability to use systematic approach to problem solving and troubleshooting. Extensive knowledge of managed care/health care administration, policy and compliance. Demonstrates ability to manage multifaceted projects in conjunction with day-to-day activities. Excellent interpersonal and customer service skills, ability to work collaboratively with other corporate groups (such as Compliance Department, and Information Systems), external vendors and State and Federal entities. Self-motivated and takes initiative: identifies, acts on, and documents solutions for gaps and opportunities for process improvements.
Bachelor’s Degree (Required)
1. Three years of direct health care experience with a specific emphasis on Government Health Program operations, regulatory issues, policy development, or compliance required.
PTCB Certified Pharmacy Technician (Required)
All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.
Denver Health is an integrated, efficient, high-quality academic health care system that is considered a model for the nation. The Denver Health system includes the Rocky Mountain Regional Level I Trauma Center, a 525-bed acute care medical center, Denver’s 911 emergency medical response system, 8 family health centers, 15 school-based health centers, the Rocky Mountain Poison and Drug Center, the Denver Public Health Department, an HMO, and The Denver Health Foundation.
As Colorado’s primary safety net institution, Denver Health is a mission-driven organization that has provided more than $3.3 billion in care for the uninsured in the last ten years. Denver Health is a leader in performance and quality improvements and remains financially secure, in part, due to its nationally recognized implementation of lean principles in healthcare. Denver Health is a major resource to the community, serving approximately 185,000 individuals and 67,000 children a year.
Located just south of downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.
We strongly support diversity in the workforce and Denver Health is an equal opportunity employer (EOE).
“Denver Health is committed to provide equal treatment and equal employment opportunities to all applicants and employees. Denver Health is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.”Position Description »