Compliance Lead, Pharmacy

This is a fully remote position, open to applicants in United States.

📋 Description

• Ensure adherence to governmental regulations pertaining to Pharmacy operations.

• Create and execute compliance policies and procedures for Medicare Parts B and D.

• Investigate compliance matters and propose modifications that address contract requirements and regulatory guidance.

• Clarify regulatory and contractual obligations for Humana departments and external partners.

• Formulate strategy and provide continuous oversight and monitoring of Pharmacy performance.

• Aid in conducting risk assessments and help shape annual audit and monitoring plans.

• Complete compliance tasks for the Medicare Prescription Payment Plan, AIP D-SNP, new implementations, and CMS initiatives.

• Conduct audits and monitor pharmacy and Medicare Part D programs, reporting key risks and remediation strategies to Regulatory Compliance leadership.

• Engage in regulatory audits and coordinate the implementation of corrective action plans.

• Maintain relationships with governmental agencies and present findings to external regulators.

• Review and evaluate regulatory documents and data to demonstrate compliance.

• Collaborate across operational units and product lines for data analytics and operational enhancements.

• Perform assessments, create action plans, and provide guidance to internal business units.

• Foster relationships with pharmacy business units.

• Support the Compliance Manager and senior associates.

• Conduct briefings and area meetings while collaborating across departments.

⛳️ Requirements

• Bachelor’s degree.

• Five (5) years of experience in pharmacy claims operations.

• A minimum of four (4) years of experience in compliance, risk management, and/or managed care.

• At least four (4) years of experience interpreting complex regulatory guidance.

• Background in auditing and consulting.

• Experience working with regulatory agencies, including CMS and/or state departments of health insurance.

• Understanding of healthcare industry regulations.

• Familiarity with PBM (Pharmacy Benefit Manager) operations.

• Ability to interpret and communicate guidance to diverse audiences in a highly matrixed environment.

• Strong communication skills and the ability to influence decisions and achieve stakeholder alignment.

• PharmD, Juris Doctorate, or a master’s degree is preferred.

• Certification in healthcare compliance (CHC, CCEP) or similar is preferred.

• Minimum 25 Mbps download and 10 Mbps upload internet service for home or hybrid work.

• A dedicated workspace free from interruptions to safeguard PHI/HIPAA information.

• Availability to work Monday–Friday, 8:30am–5:00pm EST with some flexibility.

• Up to 5% travel may be necessary, including occasional travel outside the state of residence.

🏝️ Benefits

• Bonus incentive plan based on company and/or individual performance.

• Medical benefits.

• Dental benefits.

• Vision benefits.

• 401(k) retirement savings plan.

• Paid time off.

• Company holidays.

• Personal holidays.

• Paid parental leave.

• Paid caregiver leave.

• Short-term disability.

• Long-term disability.

• Life insurance.

• Remote work arrangement.

• Optional hybrid home/office arrangement for candidates living in and around Louisville, KY.

• Up to 5% travel support for regulatory audits and occasional travel for training or meetings.