Pharmacy Compliance Specialist

Welcome to Montage Health’s application process!

Job Description:

Company Overview

Aspire Health Plan is a locally owned Medicare Advantage HMO that provides comprehensive medical coverage to seniors and other Medicare recipients in Monterey County. We’re proud to be a community-centered organization backed by Montage Health and Salinas Valley Memorial Health System. Over 700 doctors, many other healthcare providers, and all four Monterey County hospitals are part of the Aspire Health Plan network. It’s the care you need from people you know.

Purpose of Position

Under the leadership of the department Director, the Pharmacy Compliance Specialist is a key member of the Aspire Health Plan Pharmacy team, responsible for ensuring compliance with all applicable federal and state regulations, as well as Medicare Part D and Centers for Medicare and Medicaid Services (CMS) guidelines. This role involves monitoring and auditing pharmacy operations, developing and implementing compliance programs, and working cross-functionally across the pharmacy team to support compliance and utilization management. This position will also assist in the preparation of reports, coverage determinations, and utilization management for Part B and Part D. The Pharmacy Compliance Specialist will work alongside the Pharmacy Director to support the oversight of delegated entities to improve transparency, accountability and facilitate cross-functional work including internal business units and/or external entities to correct performance deficiencies.

Essential Duties and Responsibilities:

Compliance

Supports the Pharmacy Director in the following areas to ensure compliance with all applicable laws and regulations:

• Develop, maintain, and monitor Policies and Procedures (P&Ps), Compliance Program, and key performance indicators
• Review, approve and suggest revisions on policies and procedures, member/provider materials, compliance work plans, etc., as well as submit to regulatory entities for approval.
• Implement and maintain workflows and required ancillary documents for CMS Part C & D Data Validation, and other activities as required.
• Conducts regular internal audits to assess compliance with P&Ps and identify areas for improvement.
• Work with internal business units to identify gaps, develop and implement corrective action plans and facilitate monitoring activities to ensure compliance with regulatory requirements.
• Surfaces any gaps in processes that may require remediation to the Pharmacy Director.

Regulatory Monitoring

• Stay informed about the latest developments in Medicare Advantage regulations and guidance regarding Medicare Part D, such as CMS regulations and HPMS memos.
• Monitor CMS guidance and transmittals to ensure compliance with all requirements.

Auditing and Monitoring

• Assist the Pharmacy Director in establishing a robust auditing and monitoring program to assess compliance with regulatory requirements.
• Conduct regular audits of pharmacy operations, claims processing, formulary management, and other areas to identify compliance risks and ensure adherence to P&Ps.
• Prepare and submit required compliance reports to regulatory authorities as necessary
• Perform regular audits of pharmacy claims, prior authorizations, and other pharmacy-related activities.
• Conduct audits of network pharmacies to ensure compliance with contractual agreements and regulatory requirements.

Reporting and Documentation

Assist the Pharmacy Director in the development and maintenance of accurate records of compliance activities and audits, including

• Recommend process improvements and Corrective Action Plans (CAPs) to achieve and maintain compliance.
• Preparation of responses to regulatory audits and inquiries
• Submission of compliance reports to the Pharmacy Director and other stakeholders.

Delegated Entities

Support the Pharmacy Director in monitoring the compliance of delegated entities (e.g., PBMs) with contractual obligations and regulatory requirements, including but not limited to:

• Ensuring that the review, coding, and quality control of formulary changes occur in an appropriate, accurate, and timely manner.
• Collaborating to address compliance issues and ensure alignment with contractual obligations.
• Monitors daily issue/response files with PBM for claim resolution and outreach PBM for refills, claim reprocessing, and to members to provide status of intervention.