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AUDIT & OVERSIGHT MANAGER - PHARMACY SERVICES

Company: Presbyterian Health Services Corp.
Location: Albuquerque
Posted on: February 16, 2020

Job Description:

Overview

Job Description
Type of Opportunity: Full Time
FTE: 1.000000
Exempt: Yes
Work Schedule: Days

Summary:
Responsible for direct oversight of sub-contracted PBM and other pharmacy vendors. Ensures that services to Presbyterian members are delivered in accordance with client contracts including state and federal regulations/guidance. Responsibilities include ongoing audits of subcontractor and internal pharmacy operations; development and approval of policies and procedures; ongoing development and monitoring and tracking of corrective action plans; and measuring and reporting progress of corrective action plans to internal Presbyterian departments and committees as appropriate. Interfaces closely with Presbyterian pharmacy operations and other Presbyterian departments to ensure adherence to all contractual requirements; including state and federal contract requirements. Supports the Presbyterian Grievance / Appeal / Fraud / Abuse Coordinator to ensure reporting, tracking and resolution of pharmacy issues reported. Serves as a liaison between the PBM sub-contractor and the Presbyterian Compliance Officer, PHI Delegation Manager and other staff as necessary.

Responsibilities

Responsibilities:
*Develop and maintain policies and procedures related to the review and audit of PBM and other pharmacy sub-contractor obligations, delegated services and performance criteria including claims adjudication accuracy.

*Develop schedule for conducting PBM claims adjudication audits through external audit vendor.

*Develop and maintain policies and procedures related to maintaining compliance with applicable Federal and State regulations/contract terms including functions provided internally as well as those contracted to external vendors.

*Develop a schedule and coordinate processes needed to review and audit compliance with policies and procedures, maintain record of audit findings.

*Determine which oversight activities should be conducted internally and which should be delegated to external vendors.
*Develop/approve corrective actions plans (CAPs) as needed, to include specific areas of improvement, assigned accountability, and timelines.

*Meet and / or contact the sub-contractor as needed to provide ongoing feedback to sub-contractor with respect to the written corrective action plan

*Maintain record of compliance to all CAPs implemented.

*Conduct and/or participate in mock audits as needed for pharmacy related processes and actively prepare/participate in CMS/DHS/NCQA audits.

* Coordinate/Schedule all audits of current or potential sub-contractors to include pre-audits and additional follow up audits

*Coordinate internal/external resources to ensure that audits are conducted by the appropriate staff/vendors

*Ensure that sub-contractor operations meet PHP and regulatory guidelines by assisting in the development of policies and procedures

*Report audit findings, present corrective action plans, and report progress to appropriate PHP departments/personnel

*Serve as a point of contact for PHP in the area of pharmacy sub-contracted services

*Serve as a liaison between Presbyterian and sub-contractor to ensure timely reporting, acknowledgement and resolution of complaints / grievances and suspected fraud and abuse cases which are reported directly to the sub-contractor

*Monitor trends in complaints which impact access, availability and quality of services and collaborate with sub-contractor to effect improvement

*Perform other functions as required.

Qualifications

Requirements:
Bachelors degree required and five+ years experience in the pharmacy department of a Health Plan or PBM or equivalent experience in auditing/compliance. Demonstrated ability to communicate effectively in person, via telephone, and in writing with representatives of government agencies, the public, including physicians, physician office staff, other providers and members. In-depth understanding of sub-contractor roles in the delivery of care to Presbyterian members. Requires detailed coordination, organizational and project management skills.

Must be able to work cooperatively with other employees and departments and function effectively under pressure. Familiarity with Windows and Microsoft Office products. Supervisory experience preferred

Education:
Essential:
* Bachelor Degree

Competencies and skills:
Nonessential:
* SKILL-Ability to effectively interact with customers to understand their needs and explain data
* SKILL-Microsoft Office
* Planning and coordinating organizational change
* Anticipating & Addressing Customer Needs
* Educating Employees, Customers & Transferring Knowledge
* Functioning as an Effective Contingent Member
* Diagnosing & Resolving Problems
* Acquiring & Applying Superior Skills to achieve Quality Outcomes
* Functioning as an Effective Team Member
* SKILL-Demonstrated ability to communicate effectively in person and via telephone with members, employer groups, brokers, physicians, and physician office staff using strong dialogue and customer service competencies.
* SKILL-Written communication


Benefits

Benefits
Benefits are effective day-one (for .45 FTE and above) and include:

  • Competitive salaries
  • Full medical, dental and vision insurance
  • Flexible spending accounts (FSAs)
  • Free wellness programs
  • Paid time off (PTO)
  • Retirement plans, including matching employer contributions
  • Continuing education and career development opportunities
  • Life insurance and short/long term disability programs
    About Us
    Presbyterian Healthcare Services is a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, it is the state's largest private employer with approximately 11,000 employees.

    Presbyterian's story is really the story of the remarkable people who have chosen to work here. Starting with Reverend Cooper who began our journey in 1908, the hard work of thousands of physicians, employees, board members, and other volunteers brought Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system, serving more than 700,000 New Mexicans.

    We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.

    About New Mexico
    New Mexico's unique blend of Spanish, Mexican and Native American influences contribute to a culturally rich lifestyle. Add in Albuquerque's International Balloon Fiesta, Los Alamos' nuclear scientists, Roswell's visitors from outer space, and Santa Fe's artists, and you get an eclectic mix of people, places and experiences that make this state great.

    Cities in New Mexico are continually ranked among the nation's best places to work and live by Forbes magazine, Kiplinger's Personal Finance, and other corporate and government relocation managers like Worldwide ERC.

    New Mexico offers endless recreational opportunities to explore, and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.

    AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

    SR123

    *LI-TP1

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Keywords: Presbyterian Health Services Corp., Albuquerque , AUDIT & OVERSIGHT MANAGER - PHARMACY SERVICES, Executive , Albuquerque, New Mexico

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