Company Statement

For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.

Director, Enterprise Pharmacy Analytics and Audits

📁
Director and Equivalent
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190OH Requisition #
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Responsible for developing and driving the strategy for data analytics, audits, and meeting all reporting requirements for State(s) and CMS.  Lead and mentor team to produce high quality data analytic tools that efficiently inform strategic decision-making, measure the effectiveness of program implementation and build a repository of repeatable high value queries to ensure successful pharmacy operations.  Direct and oversee the daily operation and administration of enterprise analytics, rebate processing, and audit support.  Improve the PDE acceptance rate and company finances, maximize DIR savings to reduce premium costs and increase Medicare plan membership.  Enhance internal controls through strong risk assessment skills and regulatory knowledge of State and CMS auditing.  Ensure that operational processes, workflows and documentation adhere to regulatory and accreditation requirements.

Responsibilities:

Lead Analytics and Reporting Team responsible for PDE Oversight and Reporting, HPMS Reporting, DIR Reporting, MMCOR Reporting, Client Reporting, RDS Reporting, MTM Support, Rejected Claims Reporting and Various Clinical Reports. 
  • Lead an Analytics team capable of utilizing both Pharmacy and Medical Data to create integrated information and analysis.
  • Lead a team capable of managing complex regulatory reporting such as PDE, DIR, MMCOR and HPMS reporting. Create and maintain work plan and QA/sign-off process for each of the major reporting projects.
  • Provide data and technical support to Government Program Teams such as ABII, Precluded Prescribers, Transition Drop Letters, Rejected FIR Transactions, ESRD and Hospice. 
  • Support the decision-making process by finding savings opportunities such as steering Pharmacy Benefits to Medical Benefits.
  • Automation Processes: Lead the efforts for automated solutions for Pharmacy tasks. Work with Emblem Transformation Team to create automated and streamlined Pharmacy Reporting.
  • Provide data support to RFPs, including Federal Employees Benefit Plan. Work closely with Underwriting team. Walk them through the financial guarantees provided by PBM to ensure profitability of a sale/renewal. 
  • Provide data support for implementing new programs.
  • Primary liaison with benefit consultant organization, leads the scheduled market check to improve rates with incumbent PBM and/or identifies cost savings opportunities through other PBM resource. 
  • Responsible for modernizing and automating Reporting
  • Strong knowledge of SQL Coding, Python, Tableau required
Audits & Monitoring.
  • Direct CMS Audits such as Program Audit, Program Audit Validation, Mock Program Audit, Financial Audit, Data Validation Audit, PDE Data Validation, TMPA, FAA, Timeliness Monitoring, CMS Desk Audits
  • Prepare Pharmacy Team for major audits, such as Timeliness Monitoring. Collaborates with the Data, Operations and Utilization Management (UM) areas to create the audit work plan. Manage the process of creating Universes and discusses the potential issues with the team and mitigates the issues before the audits. Hold mock audits to prepare the team for the live webinars. Following the audits, lead the efforts to improve the operational processes and UM system. 
  • PBM Monitoring: Manage the process for monitoring PBM, which oversees ~$2B drug spend for 2M membership (Medicare, Exchange, Commercial and Medicaid members). Create and maintain internal controls. Guide 3rd Party consultants to conduct Pricing and Performance Guarantee Audits and Quarterly Monitoring Reports. 
  • Other Audits: Manage activities to meet requirements on State Audits, Client Audits and Drug Manufacturer Audits 
  • Respond to requests for Acumen reporting. Ensure timely resolution of Acumen Tickets, including PDE deletions as needed in collaboration with PBM and Emblem Enrollment Team. 
  • Provide Pharmacy’s internal controls, which include weekly and monthly testing and process improvement. 
  • Lead the team reviews for the PBM data feed on a weekly basis. 
  • Work with the Controllers, Internal Auditors and Pharmacy team to identify risk areas and monitor with creating key controls. Assess Vendor SOC-1 submissions.
  • Direct and produce all internal audits.
PDE Management.
  • Oversee PDE. Lead the team to ensure claims to PDE reconciliation is accurate, rejected PDEs are corrected timely by working closely with Enrollment Team and PBM. 
  • Manager current plan year and old plan year PDE rejects. Resolve historical re-openings from Pharmacy. 
  • Lead historical PDE error resolution in preparation for PDE re-openings.  
  • Maintain PDE deletion tracker and report to Finance for reserves. 
  • Support Finance and Actuary with Annual CMS Financial Reconciliations and Financial Reopening.
Rebate Processing and Monitoring.
  • Process Pharmacy Rebates quarterly for the contracts managed by EmblemHealth and ConnectiCare, including Invoicing, Collections, Aging Monitoring, Reconciliation, preparing custom reports for Finance, Actuary and Leadership.
  • Monitor Pharmacy Rebate Processing for the contracts managed by PBM. Works with the Rebate Specialist and Data Analysts to maintain rebates Database for monthly monitoring.
  • Generate and present monthly status for leadership.
  • Lead the team to maintain and improve Medical Rebate Processing for the contracts managed by Emblem, including J-code conversion, expected rebate calculations, aging reporting and monthly leadership reporting.
  • Provide data to assist with Rebate Negotiations as needed.
Star-rating, MTM, NCQA Accreditation.
  • Lead the efforts for NCQA Accreditation Preparation for Pharmacy UM. Collaborate with Emblem Accreditation team by providing regular reports, attend mock audits and prepare case packages. Collaborate with Pharmacy team to resolve issues raised and hold monthly meetings with Pharmacy Leadership to ensure accreditation.
  • Provide analytics support to help the team identify the compliant and non-compliant members for Stars measures.
  • Manage data solutions to Pharmacy Quality Team for CMS Star-rating programs.
  • Present data support to in-house MTM program.
New Programs, New Plan Year, POS Edits Implementation Support.
  • Manage the relationship with Finance, which includes custom reporting, process walk-though, budget support and CMS Financial Reconciliations support.  Meet with the Finance team frequently to review the issues and outstanding items.
  • Represent Pharmacy at the Emblem Vendor Oversight Committee, which includes conducting and presenting audit results and coordinating with vendors and Emblem SMEs to complete audit tools. 
  • Collaborate with the Pharmacy and Accruals Team. Reports Pharmacy accruals monthly.
  • Liaise between Pharmacy and Actuary Team. 
Develop and maintain enterprise policy and procedures for member and provider communication of drug changes.
Qualifications:
  • Bachelor’s Degree in Data Management, Business Administration, or related
  • Master’s in Business Administration or Advanced degree in related field preferred
  • 10+ years of experience required
  • Strong leadership and exceptional organizational skills required
  • Intellectually curious, a strong critical thinker required
  • Leads the team for independent decision making and problem resolution skills required
  • Able to streamline processes to match department and company goals required
  • Able to find automated reporting solutions that provide valuable insights for business consumption required
  • Commitment to compliance required
  • Excellent written and verbal communication skills required
  • Knowledge of regulatory and accreditation requirements required
  • Knowledge of Health Insurance Portability and Accountability Act (HIPAA) required
  • Able to establish Strong QA process required

EEOC Statement

We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.

Sponsorship Statement

Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.

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