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AmeriHealth Caritas Director of Compliance - PerformRx in Philadelphia, Pennsylvania

Director of Compliance - PerformRx

Location: Philadelphia, PA

Telecommuter?: No

ID**: 19235

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at .


This position serves as the primary contact for Medicare and Medicaid compliance for PerformRx. The Compliance Officer is responsible for ensuring overall compliance with all Medicare and Medicaid compliance activities and programs; contributes to the development, implementation, and maintenance of system-wide compliance programs; policies, and procedures; and promotes an awareness and understanding of positive ethical and moral principles consistent with the mission, commitment, and core values of the organization and those required by federal and state law. This position will report to the AmeriHealth Caritas Family of Companies Corporate Compliance and Privacy Officer. As an essential function, this position is responsible for complying with the organization’s Corporate Compliance Program as it applies to the individual job duties, the department, and the organization.This position will exercise due diligence to detect, prevent and report unlawful and/or unethical conduct, as well as fraud, waste and abuse, by fellow co-workers, professional affiliates, and/or agents.

Specific Responsibilities include:

  • Serves as the primary compliance contact and the person responsible for ensuring overall compliance with Medicare and Medicaid compliance requirements relating to PBM program

  • Coordinates implementation of system-wide programs, policies, and procedures to ensure system compliance with applicable federal and state laws and regulations

  • Responsible for organizational compliance with CMS and State transmittals, HPMS notices, CMS and state required applications and submissions as they relate to the PBM program; this inncludes maintenance of a process to timely inform stakeholders about applicable procedural changes, regulatory and/or contractual changes

  • Develops, implements, and maintains a system for confidential reporting and investigation of compliance concerns with an appropriate response process that includes the creation of an environment that facilitates freedom to report concerns or incidents of wrongdoing without fear of retaliation, and coordination of an external reporting system (toll free hot line), coordinating with Corporate Compliance when indicated

  • Coordinates with corporate compliance and/or legal counsel, as may be appropriate, in response to identified compliance questions, concerns, or federal/state inquires or investigations

  • Maintains an “open door” policy and directs efforts to communicate compliance programs, including written materials and training programs designed specifically to promote understanding of compliance issues, laws and regulations, and consequences of non-compliance

  • Reviews and investigates reported issues, concerns, or questions relative to compliance matters. Provides consultative leadership and support to all entities as appropriate. Includes close coordination with the Director of Human Resources in connection with consistent enforcement of disciplinary policies and otherwise, as well as an interaction with all levels of management throughout the organization.

  • Coordinates with Program Integrity to develop and implement systems and procedures to prevent and detect fraud, waste, and abuse in connection with PBM and pharmacy services.

  • Coordinates the development, implementation, and maintenance of audit controls and measurements for internal and external processes, ensuring correct processes are in place for accurate, complete, and compliant programs across the system – including subcontractors and/or First Tier, Downstream and Related entities (FDRs)/Vendors. Works cross-functionally to ensure identified non-compliance is remediated.

  • Coordinate fulfillment of all Federal (CMS), State and other regulatory audits.

Education/ Experience:

  • Bachelor’s degree required; Master’s degree or Graduate degree preferred

  • A minimum of five (5) years of current/recent management experience in the Medicare Managed Care, Medicaid Managed Care, Commercial Payer and/or Pharmacy Benefit Management is required

  • Healthcare and/or Regulatory related degree

  • Clinical Pharmacy, Pharmacy Technician and/or Pharmacy Operations subject matter expertise preferred

  • National Pharmacy Technician Certification (ExCPT, NCCT or PTCB) is a plus

  • Previous leadership and/or Compliance or Regulatory experience at a Pharmacy Benefit Management organization

  • Extensive healthcare software and word processing experience

  • Strong leadership, interpersonal, and problem solving skills

  • Excellent communication (listening, verbal and written) skills

  • Demonstrates personal traits of a high level of integrity, team orientation, professionalism, and trustworthiness

EOE Minorities/Females/Protected Veterans/Disabled