Find & Apply For Clinical Auditor / Utilization Reviewer Jobs in Topeka, Kansas

Home Full time R-16970 At Prime Therapeutics (Prime), we are a different kind of PBM , with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us. Job Posting Title Regulatory Analyst - Remote Job Description The Regulatory Analyst is responsible for leading portions of regulatory assessment, external audits and accreditation processes within the Commercial, Medicare, Medicaid, and Health Insurance Marketplace for the assigned department. This position is responsible for primary point of contact for internal and external business partners regarding related regulatory activity and quality efforts involving utilization and/or medication therapy management, client delegation agreements and accreditation entities, SOP development and maintenance. Responsibilities

+ Participate in portions of external audits as directed by the Centers for Medicare & Medicaid Services ( CMS ), Medicaid, NCQA , participate in commercial and Client driven external audits, annual reviews, and pre-delegation reviews and lead assigned department (i.e. Clinical Operations, PBM Operations) portions of ongoing Accreditation processes

+ Assist in Regulatory Review Committee Meetings, Healthcare Reform Meetings, Regulatory Oversight Meetings, CMS User Calls, and Government Programs Compliance Committee Meetings to monitor new regulations and provide necessary updates to these committees

+ Lead the Client, external auditor, and/or accreditation reviewer through Prime's business processes and provide the appropriate documentation and/or data files as they relate to accreditation standards or regulations

+ Maintain regulatory and accreditation gap status reporting to keep all constituencies informed; track, manage, and report on work stream status against plan

+ Lead all efforts for response to inquiries related to the assigned department, which may include pulling pertinent case files/samples, validating regulatory requirements, and review and validation of processes against requirements

+ Take lead on change management related to regulatory requirements

+ Other duties as assigned Minimum Qualifications

+ Bachelor's degree in business, finance, health services or related area of study, or equivalent combination of education and/or relevant work experience + 3 years of PBM , healthcare, and/or compliance work experience

+ Must be eligible to work in the Uni To view full details and how to apply, please login or create a Job Seeker account