Manager Pharmaceutical Financial Investigations and Provider Review

Requirements

• 5 years of auditing, leading provider / facility audits and/or provider reimbursements, or in the health care industry with exposure to billing, coding
• 3 years of clinical pharmacy management experience including drug use review activities, operational oversight and/or member engagement – knowledge of pharmacy/drug related FWA and experience working with law enforcement agencies (e.g. DEA)
• 1 year working with regulatory entities such as CMS, NCQA, HEDIS, and DOH etc.
• 3 years in a managed care pharmacy and/or pharmacy benefit management (PBM)
• 1 years in managing or supervising clinicians (such as pharmacists, nurses, or other clinicians) in a utilization management operations setting in a PBM or Health Plan.
• Pharmacist License
• None
• Strong analytic skills with ability to interpret, evaluate and act on productivity, clinical and financial data
• Strong leadership skills with demonstrated success in building effective, collaborative teams
• Ability to work in a high performing team environment that requires flexibility
• Strong and effective verbal and written communication skills; Effectively presents complex topics in a concise manner to audiences at various levels and various sizes; Demonstrates the ability to effectively persuade others to listen, commit, and act on a new approach
• Knowledge of hospital reimbursement strategies; medical technologies, hospital and provider office protocols, documentation requirements, State and Federal criminal and civil law related to insurance fraud and advances in the post-payment utilization review process
• Self-confident with an ability to accept and respond to challenges in a positive manner
• Broad understanding of business issues, metrics, organizational linkages and customer value
• Comprehensive knowledge of legal and investigative procedures used in the detection and successful resolution of health care fraud/abuse cases
• 0% - 25%
• Travel regularly from the office to various work sites or from site-to-site
• Works primarily out-of-the office selling products/services (sales employees)
• Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements. Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law. California Consumer Privacy Act Employees, Contractors, and Applicants Notice