Regulatory Pharmacy Technician

Under the direct supervision of the Manager of Regulatory Pharmacy and Oversight, the Regulatory Pharmacy Technician will provide oversight for Medicare, Medicaid, and Commercial-related pharmacy and medical benefit programs to ensure compliance with federal, state and local laws, rules and regulations. The primary responsibility of this position is to ensure Neighborhood's Pharmacy Benefit Manager (PBM) adheres to the administration of product benefit design for Medicare Part D, Commercial and Medicaid drug benefits. Secondary responsibility will be oversight of medical benefit delegated services. This role will lead non-clinical oversight functions including but not limited to claim adjudication, coverage determination timelines, marketing materials, regulatory reporting, continuity of care regulations, member and provider letters, and support internal areas to ensure pharmacy departmental regulatory requirements are met. The Regulatory Pharmacy Technician may also assist in performing day-to-day operational tasks, which include working closely with the pharmacy technicians, pharmacists and other departments with Pharmacy Department related issues, as needed.

Duties and Responsibilities:

Responsibilities include, but are not limited to the following:

• Collaborate with other areas such as Product, Grievance and Appeals (GAU), Compliance, Special Investigations Unit (SIU), Enrollment and internal operation teams.
• Support performing vendor/First Tier, Downstream and Related Entities (FDR) management program oversight for regulatory and operational requirements. FDR oversight responsibilities include developing and managing a robust oversight program for PBM and other delegated services that includes oversight of coverage and organization determinations, transition policy, benefit coding, marketing materials including website and member/provider portals, and letter template compliance/maintenance.
• Support internal and external audits as needed and responsible for meeting regulatory deadlines that may require work after hours
• Support compliance with accreditation and regulatory requirements such as federal and state government regulations, Medicare/CMS, NCQA and state regulators.
• Compliance encouraging functions include but not limited to encouraging the management of Corrective Action Plans (CAPs) through resolution (both internal and external), audit support for all lines of business, Medicaid and Commercial Core reporting, internal mock audits, NCQA, Medicare regulatory requirements (i.e., annual Call Letter and Checklist, Health Plan Management System (HPMS) Memos/Chapter updates, compliance indicators).
• Support efforts in Pharmacy Department-related member and provider communication materials.
• Conduct internal audits to ensure the pharmacy department adheres to standard methodologies and Desktop Procedures (DTPs).
• Responsible for ensuring Neighborhood's Pharmacy Department webpages are current and accurate including prior authorization criteria, clinical medical policies, formulary, links, plan finder, explanations to file a coverage determination or redetermination request, etc.
• Perform other duties and responsibilities as assigned
• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.

Qualifications

Required:

• Active Certified Pharmacy Technician I Rhode Island license
• Minimum of three (3) years' experience working in Pharmacy, Pharmacy administration or Pharmacy claims processing
• Strong analytical skills
• Ability to resolve issues and complete required duties with little supervision
• Ability to prioritize multiple tasks and deadlines
• Strong verbal and written communication skills including presentation skills
• Intermediate to Advanced skills in Microsoft Office (Word, Excel, Outlook, and PowerPoint)

Preferred:

• Active Certified Pharmacy Technician II Rhode Island license
• At least one (1) year of pharmacy managed care experience
• Medicare Part B and D regulatory, compliance and oversight experience

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. 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.