Senior Regulatory Specialist

The Senior Regulatory Specialist – Pharmacy is responsible for promoting compliance with regulatory requirements within Healthfirst's Pharmacy and Dental departments and/or delegated vendors. Compliance is promoted by ensuring regulatory updates are evaluated and properly implemented, along with performing monitoring to evaluate compliance with regulatory requirements required by Centers for Medicare and Medicaid Services (CMS) and State Department of Health (DOH) regulations, and business requirements. The role also entails supporting the maintenance and oversight of the Restricted Recipient Program (RRP).Duties & ResponsibilitiesMonitor incoming regulations including those received from Centers for Medicare and Medicaid Services (CMS), State Department of Health (DOH), Office of Medicaid Inspector General (OMIG) and other channels.Share regulatory guidance with Pharmacy department and provide support to ensure regulation and impact are understood. Act as a liaison between Pharmacy Department and Regulatory Affairs/Legal when guidance on interpretation is required.Provide support to Pharmacy Department related to regulatory implementation efforts including:Tracking deliverables to targetCoordinating meetings and collecting deliverables from business units.Capturing action stepsCommunicating to leadershipCoordinate monthly meetings with the RRP review team and in collaboration with other departmentsSupport all RRP committee meetings and be responsible for documenting attendance and monthly meeting minutesData analysis of pharmacy and medical claims data to identify potential candidates for RRPReview claims reporting to identify inappropriate fraud, waste, and abuse trends resulting in referral for review by the RRP committee for potential restrictionParticipate in monthly OMIG meetings and subsequently meet with internal stakeholders to review determine actionable itemsManage and maintain proper documentation of the RRP roster. This includes managing referrals from OMIG, members transitioning into the plan under previous MCO or fee for service (FFS) restriction and ensuring timely reviews of members up for re-restriction are being conducted. Also includes maintaining detailed summary reviews, determinations, and appeals associated with memberProcess new enrollee RRP notices to new members joining the plan with restrictions under a previous MCO or FFSProcess provider notifications when a provider is designated as a member’s restricted provider.Process restriction change requests from members, OMIG, and DOHConduct monthly, quarterly, and annual monitoring for the processes of RRP to reduce compliance risksTriage RRP Inbox requests and prioritize tasks based on urgency, importance, and service level agreement (SLA)Process Fair Hearing requests within one business day of receiptAssist with state audits, with data analysis of pharmacy and medical claims dataIdentify process gaps or process improvements and collaborate with Pharmacy department and other business units to implement process enhancements.Creating comprehensive corrective action plans.Attend Regulatory, Pharmacy and departmental meetings, as deemed appropriate.Additional duties as assigned.MinimumQualificationsHigh School Diploma or GED from an accredited institutionWorking knowledge of CMS and state regulatory requirementsPreferred QualificationsBachelor's degree from an accredited institution.Knowledge of regulations of Medicaid Services and the New York State Department of HealthManaged Care experiencePharmacy experienceHiring Range*:Greater New York City Area (NY, NJ, CT residents): $83,100 - $120,360All Other Locations (within approved locations): $73,400 - $109,225As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.