Compliance Oversight Analyst - Pharmacy Programs

JOB SUMMARY:
Responsible for the development, implementation and monitoring of compliance plans based on state and federal regulations. This includes evaluation of regulations, education of affected staff, and periodic audits of operational areas and delegated vendors to ensure effective ongoing regulatory compliance. Research and respond to inquiries and complaints submitted to regulatory agencies by members and providers.


REPRESENTATIVE JOB DUTIES:
Develop, implement and monitor regulatory compliance plans and strategies including evaluation of state and federal regulations, assessments of organizational and delegated vendor compliance, preparation of periodic reports to senior management, review of Corporate and delegated vendor policies, procedures and reports and monitoring of corrective actions.

Maintain a thorough and comprehensive understanding of plan business practices to effectively assess the impact of regulatory requirements.

Educate plan and delegated vendor staff as necessary regarding regulatory requirements and compliance activities. Assist Corporate and delegated vendor staff in the development of policies and procedures to comply with regulatory requirements. Maintain accurate and comprehensive documentation of compliance activities as needed to successfully meet requirements of external agency audits.

Conduct periodic and/or focused audits of the Corporate departments impacted by regulatory requirements to assess their compliance. Conduct annual and focused reviews of delegated vendors to monitor compliance with regulatory requirements. Develop and maintain effective audit tools that incorporate all regulatory requirements.

Develop comprehensive delegation agreements that outline the requirements that must be met by the vendor. Assist in the selection of new delegated vendors through the RFP process. Conduct pre-delegation assessments of potential new delegated vendors to ensure that they are compliant prior to the agreement going into effect.

Prepares submissions to regulatory agencies of compliance activities and related documentation as required to receive agency approvals or in response to agency requests. Coordinate audits conducted by regulatory agencies.



KNOWLEDGE, SKILLS & ABILITIES REQUIRED:

Knowledge of:
Health care financing, delivery, operational functions and regulatory requirements.


Technical Skills:
Well-developed verbal and written communication skills and experience in presenting complex issues to different audiences is essential.
Personal computer skills and demonstrated project management background are essential.


Ability to:
Handle sensitive matters professionally and confidentially.
Handle multiple priorities.
Exercise sound judgment.
Perform other duties as assigned.
QUALIFICATIONS:

Minimum Education and Experience:
Bachelorâ??s degree in Nursing, Business Administration, Finance/Accounting or a combination of applicable work experience, training and course work.
Five to seven years experience in health care regulatory compliance activities or health care plan operations.



Preferred Education, Additional Qualifications and Experience:
Masterâ??s degree.
Medical policy and benefit knowledge; contract knowledge and knowledge of provider risk arrangements.


BCBSRI values diversity and is an equal employment opportunity/affirmative action employer m/f/d/v.
REQUIREMENTS
JOB SUMMARY:
Responsible for the development, implementation and monitoring of compliance plans based on state and federal regulations. This includes evaluation of regulations, education of affected staff, and periodic audits of operational areas and delegated vendors to ensure effective ongoing regulatory compliance. Research and respond to inquiries and complaints submitted to regulatory agencies by members and providers.


REPRESENTATIVE JOB DUTIES:
Develop, implement and monitor regulatory compliance plans and strategies including evaluation of state and federal regulations, assessments of organizational and delegated vendor compliance, preparation of periodic reports to senior management, review of Corporate and delegated vendor policies, procedures and reports and monitoring of corrective actions.

Maintain a thorough and comprehensive understanding of plan business practices to effectively assess the impact of regulatory requirements.

Educate plan and delegated vendor staff as necessary regarding regulatory requirements and compliance activities. Assist Corporate and delegated vendor staff in the development of policies and procedures to comply with regulatory requirements. Maintain accurate and comprehensive documentation of compliance activities as needed to successfully meet requirements of external agency audits.

Conduct periodic and/or focused audits of the Corporate departments impacted by regulatory requirements to assess their compliance. Conduct annual and focused reviews of delegated vendors to monitor compliance with regulatory requirements. Develop and maintain effective audit tools that incorporate all regulatory requirements.

Develop comprehensive delegation agreements that outline the requirements that must be met by the vendor. Assist in the selection of new delegated vendors through the RFP process. Conduct pre-delegation assessments of potential new delegated vendors to ensure that they are compliant prior to the agreement going into effect.

Prepares submissions to regulatory agencies of compliance activities and related documentation as required to receive agency approvals or in response to agency requests. Coordinate audits conducted by regulatory agencies.



KNOWLEDGE, SKILLS & ABILITIES REQUIRED:

Knowledge of:
Health care financing, delivery, operational functions and regulatory requirements.


Technical Skills:
Well-developed verbal and written communication skills and experience in presenting complex issues to different audiences is essential.
Personal computer skills and demonstrated project management background are essential.


Ability to:
Handle sensitive matters professionally and confidentially.
Handle multiple priorities.
Exercise sound judgment.
Perform other duties as assigned.
QUALIFICATIONS:

Minimum Education and Experience:
Bachelorâ??s degree in Nursing, Business Administration, Finance/Accounting or a combination of applicable work experience, training and course work.
Five to seven years experience in health care regulatory compliance activities or health care plan operations.



Preferred Education, Additional Qualifications and Experience:
Masterâ??s degree.
Medical policy and benefit knowledge; contract knowledge and knowledge of provider risk arrangements.


BCBSRI values diversity and is an equal employment opportunity/affirmative action employer m/f/d/v.