Harbor Health is seeking a talented Part D Program Compliance Manager to join our team at the Elder Service Plan (ESP) with locations in Mattapan and Brockton.
Our position is full time, primarily remote work, but must be able to travel to our Plan sites as needed.
Harbor Health offers an excellent, comprehensive benefits package including Health, Dental, Vision, Life, & Disability insurance, 403b Savings Plan, Generous Paid Time Off plus 11 additional Holidays and much more!
Under the direction of the Quality and Compliance Director, the Part D Compliance Program Manager is responsible for administering the Part D Compliance Program for Harbor Health’s Program for All Inclusive Care for the Elderly (PACE).
The Part D Compliance Program Manager will serve as the internal and external liaison for all Medicare Part D regulations and ensure that our members receive the highest quality care and prescription drug coverage. The Part D Compliance Program Manager will work cross functionally with various departments, including finance, pharmacy, and compliance to monitor, analyze, and continuously improve our adherence to Part D requirements. The Part D Compliance Program Manager will be responsible to develop and maintain a relationship with our Pharmacy Benefit Manager (PBM), while also acting as the Chair of the Part D Compliance Committee.
Part D Compliance Program Oversight
- Ensures the successful operations and compliant administration of the Medicare Pharmacy (Part D) program.
- Ensures adherence to all regulations and guidelines set forth by the Centers for Medicare & Medicaid Services (CMS) related to Medicare Part D.
- Responsible for relationship management, oversight, and primary contact with the PBM.
- Accountable for managing processes related to PBM performance, their ability to meet CMS compliance for all delegated activities, Part D adjudication of benefits, and pharmacy audits.
- Acts as the PACE lead on the Quarterly Executive Review meeting with the PBM.
- Handles escalated issues related to Part D compliance.
- Leads internal and external audits of the Part D program.
- Conducts regular internal audits (Fraud, Waste and Abuse and Part D) and monitors activities to identify and rectify any non-compliance issues.
- Provides training and educational resources to ESP staff regarding Medicare Part D compliance and keeping them informed about regulatory changes and best practice.
- Conducts investigations into compliance-related concerns, reports findings to the ESP Director of Quality & Compliance, and assists in resolving issues.
- Reviews the compliance practices of third-party vendors to ensure their operations align with Part D regulations.
- Identifies areas for improvement in compliance processes and collaborates with relevant departments to implement changes.
- Responsible for Health Plan Management System (HPMS) memo review and circulation to impacted staff.
- Fosters a culture of compliance within the organization and serves as a point of contact for compliance-related inquiries.
- Supports the finance department as needed for completion of the Part D bid and 1/3 Financial Audit.
- Generates and monitors compliance reports and communicates findings to the leadership team, making recommendations for corrective actions when necessary. Report monitoring includes, but is not limited to: Prescription Drug Event (PDEs), Fraud, Waste and Abuse (FWA) reporting, Acumen reporting, Part B vs. D drug reporting, Financial Information Reporting (FIR), Enrollment Data Validation (EDV) reporting and Milliman and Pharmastar reporting.
Policies and Procedures
- Maintains accurate and up-to-date documentation of all compliance-related activities, policies, and procedures utilizing compliance software and Excel.
- Collaborates with the Finance and Compliance teams to develop, implement, and update policies and procedures in line with Part D requirements.
- Meets regularly with the PBM to ensure CMS and contractual compliance with all pharmacy/medical drug related policies and processes.
- Bachelor’s degree in healthcare administration or a related field required, Master’s in related field preferred.
- Minimum of 3 years of experience in healthcare compliance, with a focus on Medicare Part D regulations.
- In-depth knowledge of CMS Part D guidelines and regulations.
- Strong analytical, organizational, and problem-solving skills.
- Excellent written and verbal communication skills.
- Detail-oriented with the ability to work independently and as part of a team.
- Proficiency in using compliance management software - Compliatric experience preferred.
- Intermediate Microsoft Office 365 skills including, Word, Outlook, and Advanced Excel.
- Ability to maintain confidentiality and act in the company’s best interest.
- Professional certification in healthcare compliance preferred.
- Experience working in a PACE Program, Medicare Advantage or Prescription Drug Plan (PDP) setting preferred.
- Must be able to travel between Harbor sites in a timely manner.
Harbor Health Services is an innovative, growing, mission-based organization that lives, serves and collaborates with our community members to achieve our mission to help individuals reach their full potential through access to local, affordable services that promote health. Harbor provides medical, behavioral health, dental, and support services to more than 34,000 patients in Boston, the South Shore, and Cape Cod. Harbor Health also operates two Programs for All-Inclusive Care for the Elderly in Mattapan and Brockton, providing comprehensive healthcare, transportation and social services for more than 580 frail elders who continue to live with dignity and independence in the community and a Woman, Infants and Children (WIC) Nutrition Program.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.