Compliance Lead - Government Pharmacy Benefit Management

RxSense is a leading healthcare technology company delivering innovative solutions for pharmacy benefits and prescription savings. Our enterprise platform brings transparency, flexibility, and efficiency to pharmacy benefit management, helping clients streamline operations and enabling consumers to save on prescriptions. By integrating intelligence across the pharmacy ecosystem, RxSense makes cost-effective healthcare more accessible. Whether for PBMs, pharmacies, or individuals, our solutions help modernize operations, reduce costs, and improve outcomes. 

RxSense also owns and operates SingleCare, a free prescription savings service that offers consumers access to consistently low prices on prescription drugs. Through its partnerships with the country’s largest pharmacies and grocers, including CVS, Walgreens, Walmart, Kroger and Albertsons, SingleCare improves access and adherence to affordable medications and has helped millions of Americans save over $11 billion on their medications. 

RxSense is a great place to work! Our company has earned several prestigious awards, including Fast Company’s Most Innovative Companies, Forbes’ Top Startup Employers, Modern Healthcare's Best Places to Work in Healthcare, and Inc’s Best in Business and Best Workplaces.

Position Overview:

The Compliance Lead will establish and oversee the comprehensive compliance program infrastructure for our pharmacy benefit management operations, with specialized focus on government healthcare programs including Medicare Part D, Medicaid, and ACA marketplace plans. This high-visibility position is critical for establishing program credibility, ensuring operational integrity, and maintaining adherence to complex federal and state regulatory requirements.

Key Responsibilities:

Compliance Program Development

• Establish and maintain comprehensive compliance program infrastructure meeting CMS requirements
• Develop and implement compliance policies, procedures, and internal controls for all PBM operations
• Create written compliance plans incorporating the seven elements of an effective compliance program
• Design and oversee compliance training programs for all staff levels
• Establish compliance committee structure and governance framework

Regulatory Monitoring & Oversight

• Monitor evolving federal and state regulations affecting PBM operations
• Interpret CMS guidance, HPMS Memos, DHHS-OIG advisories, and state regulatory updates
• Develop compliance monitoring protocols and oversight mechanisms
• Create regulatory change management processes to assess operational impact
• Maintain regulatory compliance calendar for all reporting requirements

Audit & Risk Management

• Develop comprehensive audit frameworks for CMS, state Medicaid, and internal compliance and readiness reviews
• Prepare organization for CMS program audits across all audit domains (ODAG, CDAG, formulary administration)
• Create mock audit programs and readiness assessments
• Establish corrective action plan (CAP) development and tracking systems
• Implement fraud, waste, and abuse (FWA) detection and prevention programs

Government Program Compliance

• Ensure Medicare Part D compliance including:
• Coverage determinations and appeals processes
• Formulary management and P&T committee oversight
• Beneficiary communications and marketing materials
• Part D reporting requirements and data submissions
• Medication Therapy Management (MTM) program compliance
• Manage Medicaid compliance requirements:
• State-specific pharmacy benefit requirements
• Managed care organization (MCO) pharmacy services contract compliance
• Oversee ACA marketplace compliance:
• PBM transparency reporting requirements
• Rebate and discount disclosure protocols
• Price concession reporting standards

Operational Integration

• Embed compliance controls directly into operational workflows
• Partner with operations teams to develop compliant processes
• Review and approve all member materials, communications, and system configurations
• Establish prior authorization and utilization management compliance protocols
• Ensure pharmacy network contracts meet regulatory requirements

Risk Mitigation & Enforcement

• Conduct risk assessments across all operational areas
• Develop risk mitigation strategies and monitoring plans
• Manage regulatory investigations and enforcement actions
• Oversee respons