Job Description

Job Description

Job Description

POSITION SUMMARY

The Compliance Associate reports directly to the Compliance Director and plays a key role in ensuring the organization’s adherence to all applicable federal and state regulations, contractual obligations, internal policies, procedures, and standard operating procedures (SOPs) with a particular focus on Medicare-related requirements.

The CA supports the development, implementation, monitoring, and oversight of comprehensive compliance programs designed to mitigate risk, uphold regulatory standards, and promote ethical business practices across all operational areas. The Compliance Associate collaborates with various departments to identify potential compliance risks and assists in conducting audits and investigations to address any issues. Ultimately, the Compliance Associate contributes to the organization's mission by ensuring operational compliance and protecting both patients and the organization from legal and regulatory challenges.

ESSENTIALS ROLES AND RESPONSIBILITIES

1. Draft agreements, amendments, and legal documents, etc., according to Company directions.
2. Track the execution of legal documents.
3. Review applicable local, Medicare and state regulations and file any necessary information with regulatory agencies, if appropriate.
4. Monitor and interpret regulatory changes impacting PBM operations, including CMS guidelines, HIPAA, and Medicare Part D.
5. Assist in maintaining compliance with Medicare regulations, including formulary management, reporting requirements, and audit readiness.
6. Conduct periodic internal reviews or audits to ensure that compliance procedures are followed.
7. Disseminate written policies and procedures related to compliance activities.
8. File appropriate compliance reports with regulatory agencies if applicable.
9. Maintain documentation of compliance activities, such as complaints received or investigation outcomes.
10. Discuss emerging compliance issues with management or employees.
11. Collaborate with other departments to ensure documents are processed and handled in a timely and efficient manner.
12. Provide employee training on compliance-related topics, policies, or procedures.
13. Assist internal or external auditors in compliance reviews, including URAC, SAE 16, and CMS audits.
14. Prepare management reports regarding compliance operations and progress.
15. Verify that all firm and regulatory policies and procedures have been documented, implemented, and communicated.
16. Direct the development or implementation of compliance-related policies and procedures throughout an organization.
17. Review or modify policies or operating guidelines to comply with changes to environmental standards or regulations.
18. Perform other duties as assigned by the Compliance Director.

TRAINING & EDUCATION

• Bachelor’s degree in healthcare administration, law, or a paralegal degree.

LICENSURE / CERTIFICATION

• Certified Compliance & Ethics Professional (CCEP) preferred

PROFESSIONAL EXPERIENCE

• 1-3 years of experience in a PBM /Health Plan environment and/or Medicare-related programs
• 1-2 years of experience working with contractual agreements.

PROFESSIONAL COMPETENCIES

Knowledge:

• Fully bilingual English and Spanish
• Knowledge of CMS regulations and Medicare compliance standards
• Proficiency in Microsoft Office 365 (Word, PowerPoint, Excel, etc.)
• Computer knowledge
• Business process understanding
• Knowledge of producing clear, structured, and accurate documentation, including reports, SOPs, and compliance materials.

Skills:

• Skill in analyzing situations accurately and taking effective action.
• Demonstrated effective organizational, interpersonal, and communication skills.
• Strong verbal and written communications skills
• Time Management Skills: Establishing priorities and accomplishing tasks in a timely manner.
• Problem-solving skills.
• Integrity and ethics
• Strategic planning
• Skills in delivering clear, engaging, and professional presentations to groups of clients, adapting tone and content to suit diverse audience.
• Client-focused communication

Abilities:

• Ability to read and interpret documents and write reports and correspondence.
• Ability for public speaking & client engagement
• Able to effectively interact with internal departments, company clients, members, and other healthcare professionals.
• Ability to work independently and with minimal supervision, demonstrating initiative
• Ability to handle sensitive or confidential information is critical.
• Teamwork: the ability to work in a team environment.

PHYSICAL AND MENTAL DEMANDS

• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk or hear, sitting, standing and walking.
• The position requires that weight be lifted and force be exerted up to 25 pounds.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

ENVIRONMENTAL AND WORKING CONDITIONS

• This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets, and fax machines. Require evening or weekend work.

PharmPix is an Equal Employment Opportunity Employer Minorities / Females / Disable / Veterans

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