AmeriHealth Caritas Manager Medicare Programs in Philadelphia, Pennsylvania

Manager Medicare Programs

Location: Philadelphia, PA

Telecommuter?: No

ID**: 16352

Job Brief

Medicare PBM Management

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 www.amerihealthcaritas.com .

PerformRx is a pharmacy benefits manager (PBM) dedicated to clinical culture, boutique service and holistic solutions. Our mission is to help customers, doctors and patients use effective medication therapy to improve health and wellness. For more than 15 years, our focus has been on providing optimal service through a clinical culture which seeks to provide members with high quality care while ensuring our partners receive favorable costs. That culture is reflected in our employees—more than 80 percent of our staff members are pharmacists and pharmacy technicians—and in the services we provide.

PerformRx is headquartered in Philadelphia with offices on both coasts, leading to better pharmacy benefit management across the nation. Our dedication to innovation and to providing the most efficacious outcomes is the core of our clinical culture and is the heart of PerformRx. PerformRx is a subsidiary of the AmeriHealth Caritas Family of Companies.

Responsibilities:

  • Manages a team of Medicare program professionals to achieve company goals

  • Ensures PerformRx’s compliance with laws and regulations relating to Federal and State requirements.

  • Medicare subject matter expert. Provides guidance to PerformRx management, associates, and clients to ensure compliance with Federal and State requirements

  • Reviews and interprets State and Federal regulatory guidance and memoranda. Oversees the implementation of any requirements with PerformRx departments and vendors.

  • Oversees any corrective action plans in instances of Medicare program non-compliance.

  • Accountable for administration of the PerformRx Compliance Committee

  • Develops comprehensive compliance program to detect and prevent fraud, waste, and abuse.

  • Manages the annual review of PerformRx policies and the development of new policies as needed.

  • Manages distribution and closure if internal and external corrective action plans

  • Oversees the successful completion of any external audits of functions that PerformRx administers on its clients’ behalf.

  • Communicates with State and Federal regulators to validate PerformRx processes. Ensures PerformRx participation in State and Federal solicitation for public comment of guidance that affects PerformRx Medicaid and Medicare business.

  • Assures PerformRx Medicare program communications are accurately interpreted and timely.

  • Assures that PerformRx associates receive general compliance/ Fraud, Waste and Abuse training upon initial hiring and annually.

  • Ensures that clients receive PerformRx Bulletins (external client communication documents) that address changes in PerformRx processes resulting from new State and Federal rules

Education/Experience:

  • Bachelor’s Degree Business, Social Science or other relevant field preferred or equivalent.

  • Certification in Health Care Compliance (CHC) or Health Care Privacy Compliance (CHPC) preferred.

  • 1-3 years' Medicaid, or Medicare Part D, or Health Care Privacy .

  • 3-5 years' People Management experience.

  • 5-10 years Compliance ( privacy, or audit, or regulatory or contractual analysis).

  • Experience applying compliance and ethics standards in a Managed Care, PBM, and or Pharmacy setting preferred.

EOE Minorities/Females/Protected Veterans/Disabled