A Clinical Auditor or Utilization Reviewer reviews the efficiency of healthcare delivery. Individuals tend to have had experience as a registered nurse or other healthcare delivery roles before transferring into this quality review role.
Either Full or Part Time, more than 6 months
SR You may contact this employer directly.
(Obtain the contact information to print or add to your jobs.) Obtain Contact Information
Job Summary 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 Sr (Remote) Job Description The Senior Regulatory Analyst is responsible for leading portions of departmental regulatory review and analysis, external audits and accreditation processes, and participates in committee review meetings within the Commercial, Medicare, Medicaid, and Health Insurance Marketplace for the assigned department. This position is responsible for being the primary point of contact for new internal and external business partners with regard to related regulatory activity and quality efforts involving utilization and/or medication therapy management, network management, client delegation agreements and accreditation entities, SOP development and maintenance, and development and maintenance of audit protocols. Responsibilities Participate 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 Monitor national and state healthcare regulation requirements and update appropriate stakeholders of changes or new requirements Take the lead on any new business issues and opportunities generated by Government and/or Commercial laws, rules, regulations or guidelines that impact Consumer Delivery Ensure successful implementation and execution of regulatory compliance requirements including project leadership and governance; ensure appropriate requirements are in place for new Client and Group implementations Establish and maintain engaged relationships with leadership of other functional areas within the corporation (can include Government Programs, Compliance, Healthcare Reform, Legal, Networks, Clinical Operations, Paper Claims, Member Materials, IT, etc.) to ensure effective collaboration, communication, and delivery of required regulations Recommend changes to policies and procedures based on regulatory changes Liaison with Internal Audit and External Audit teams to represent departments in CMS, Client, mock, and vendor audits Review audit feedback, initiate action items related to audit or compliance review findings, and recommend ideas for improvement and summarize action plans 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 5 years of successful project management and/or operations management experience related to, or within Pharmacy Benefit Management (PBM) or health insurance 2 years Medicare Part D, Medicaid, and/or federal regulatory experience Must be eligible to work in the United States without need for work visa or residency sponsorship Must be eligible to work in the United States without the need for work visa or residency sponsorship Additional Qualifications Excellent verbal and written communication skills including interpersonal skills necessary to drive results and deliver on commitments Proficient at meeting facilitation, conflict management, and consensus building Proven client service skills with a track record for building strong client relations Ability to handle multiple projects simultaneously and to work under pressure with strict timelines Proven problem solving and so... Compliance Officers
Access our Statewide and Regional occupation report for more information about wages, employment outlooks, skills, training programs, related occupations, and more.
Compensation
Not Provided
Job Requirements
