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Responsibilities

• Oversee PBM Licensing - ensures Pharmastar is appropriately licensed based on services rendered.
• Track state and federal business requirements and manages compliance with associated regulatory reporting.
• Contact regulators for clarification and guidance as necessary.
• Manage regulatory audit proceedings.
• Coodinate pharmacy audits and distributes plan specific audit result letters.
• Participate in clients' CMS financial audits providing documentation and reports as needed.
• Research regulatory issues as it relates to clients' drug benefits and report results to clients.
• Develop Corrective Action Plans (CAPs) in response to audit findings.
• Monitor Medicare Part D regulation and guidance for applicability to Pharmastar. Assists with facilitating client awareness of regulatory changes.
• Responsible for maintaining P&P related to the regulatory compliance of Pharmastar includes drafting and editing.
• Provide guidance to the Pharmastar regulatory team, including training and development.
• Communicate with staff regarding needs of both the client and the company. Follow up to ensure appropriate action is taken in a timely fashion.
• Monitor client utilization and proactively solve issues as they arrive.
• Research regulatory issues as it relates to clients' drug benefits and report results to clients.
• Assure departmental compliance with company policies, procedures, standards and regulatory requirements.
• Promote staff enthusiasm and teamwork, support others in their job functions.
• Ensure that HIPAA guidelines are followed in every communication with clients.
• Stay current on plan and benefit structures, pharmacological updates, and Medicare Part D guidelines.
• Attend department and company meetings and educational programs upon request.

Key Responsibilities simplified:

• Oversee PBM licensing across states
• Track and report on compliance with state/federal regulations
• Manage regulatory and pharmacy audits, including CMS audits
• Research and report on regulatory issues for client drug benefits
• Draft and maintain policies and procedures (P&Ps)
• Develop and implement Corrective Action Plans (CAPs)
• Support the team with training and regulatory updates
• Ensure compliance with HIPAA and company standards
• Monitor client activity and resolve issues proactively

Ideal Background:

• 5+ years in healthcare, pharmacy, or PBM setting
• Strong understanding of Medicare Part D, PACE programs, and pharmacy benefit structures
• Experience supporting regulatory or audit functions at a state level
• Associate's degree required (or equivalent experience)

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