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.

Pharmacy Analytics & Audit Leader

📁
Director and Equivalent
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190SW Requisition #
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Lead the Pharmacy Analytics team, directing the Rebates & Audit functions effectively across Pharmacy and the other departments in the enterprise. Lead the pharmacy team through all audits including state, CMS, client and internal audits including capturing the requested data, organizing input from others across the organization and representing the team at the onsite audit(s).  Perform periodic operational and performance audits of all pharmacy functions including utilization management, Medicare, Medicaid, etc.  Build a repository of repeatable high value queries for business consumption which meet all state and CMS reporting requirements.  Lead and mentor the team to take on increasing responsibility.  Manage the medical contract rebate reporting process, ensuring accurate and timely collection of rebates due to EmblemHealth and ConnectiCare.  Audit pharmacy rebate process maximizing rebate pass through from Express Scripts (ESI).  Report progress quarterly.  Define and execute solutions regarding delinquent/inaccurate payment from Pharma and Express Scripts.

Responsibilities:
  • 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.  Utilization Management (UM) Reporting
    • Partner with the Director, UM, to enhance reporting capabilities reducing the risk/eliminating elapsed cases
    • Maintain a process of daily, weekly, monthly and quarterly reporting
    • Work with UM vendor for streamlined reporting solutions
    • Create audit universes for CMS Program Audit, Timeliness Monitoring and various other CMS audits
    • Create reports for NCQA accreditation project
    • Report the results to Pharmacy leadership to help them monitor timeliness of coverage determination reviews
  • Manage Annual Health Plan Management System (HPMS) Data Submission
    • Develop quarterly review process
    • Establish strong QA process for accurate reporting
  • Pharmacy and Medical Drug Rebate Management
    • Responsible for managing medical rebate processing and submission
    • Perform QA to ensure the accuracy of the data 
    • Work with internal and external partners to understand reporting needs and ensures the timely completion of the reports
    • Responsible for maintaining databases for easy reporting solutions
  • Relentlessly pursue innovative data analytics solution, including predictive analytics
  • Follow the changes in the Health Care Industry closely and helps EmblemHealth modernization
  • Flexible to work on complex special projects to support department and company needs such as Formulary Cost Analysis, Medical UM cost analysis
  • Supervise and mentor the professional staff in the team
  • Support efforts to recruit top tier talent into the department, develop and train these individuals into a high-performance team
Qualifications:
  • Bachelor’s Degree required
  • Advanced degree in related field preferred
  • A minimum of 10 years of audit an data analytics experience required
  • Advanced SAS knowledge required
  • Strong management experience required
  • Advanced organizational knowledge 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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