Director, PerformRx Government Programs and Products
Type: Full Time
Preferred Education: 4 Year Degree
Hospital, Public and Private
4 Year Degree
Internal Number: 24229
Director, PerformRx Government Programs and Products
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. 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.
The Director, PerformRx Government Programs and Products is the primary contact for Medicare and Medicaid product development for PerformRx. The Director is the subject-matter expert (SME) for government programs and will ensure all products are functioning as expected. The incumbent is the liaison amongst Account Management, Operations and the Regulatory/Compliance Teams. The Director assists teams across PerformRx with enhancing our current operations, testing, and offerings in the government program space. The Director will exercise due diligence to detect, prevent and report unlawful and/or unethical conduct, as well as fraud, waste and abuse.
Serves as the primary contact and the person responsible for ensuring overall compliance with Medicare and Medicaid compliance requirements relating to PBM program
Coordinate implementation of system-wide programs, policies, and procedures to ensure system compliance with applicable federal and state laws and regulations.
Coordinate written policies and procedures that set up standards for compliance; provide specific guidance to management, professional staff, and individual departments as appropriate
Develop, implement, and maintain a system for confidential reporting and investigation of escalated government program concerns with an appropriate response process to incoude the creation of an environment that facilitates freedom to report concerns and/or incidents of wrongdoing without fear of retaliation; coordinate an external reporting system (toll free hot line), coordinating with PerformRx Compliance
Assist Account Management in resolution and research of issues in a timely manner, and deliver responses to clients within Account Management
In coordination with internal legal consultants, maintain awareness of laws and regulations, keeping abreast of current changes that may impact healthcare systems. Utilize personal initiative, seminars, training programs, peer contact, and various industry information sources (i.e., Internet sites, newsletters, etc.)
Work with our Claims Processor to act as a subject-matter expert (SME) in all areas of government programs implemented with our Claims Processor
Educate Account Management and other cross functional areas on government programs
Coordinate with Network Operations to develop and implement systems and procedures to prevent and detect fraud, waste, and abuse in connection with PBM and pharmacy services
Coordinate the development, implementation, and maintenance of audit controls and measurements for internal and external processes, ensuring correct processes are in place for accurate, complete, and compliant programs across the system, including subcontractors and/or First Tier, Downstream and Related entities (FDRs)/Vendors. Work cross-functionally to ensure identified non-compliance is remediated.
Communicate to and work collaboratively with the Chief Compliance Officer, President of PerformRx, the PerformRx Board of Directors, and in-house Legal counsel. Prepare monthly and/or quarterly compliance summaries for the organizations leadership, as outlined above, as well as the Compliance Committee.
Requires Bachelor’s Degree in Healthcare and/or Regulatory related degree
Master’s Degree preferred
Minimum of five (5) years of management experience in Medicare Managed Care and/or Medicaid Managed Care in a Pharmacy Benefit Management (PBM) environment required
Current/recent leadership and Compliance or Regulatory experience at a Pharmacy Benefit Management organization required
Extensive healthcare software and computer experience
Strong leadership, interpersonal, and problem solving skills
Effective communication (listening, verbal and written) skills
Demonstrates personal traits of a high level of integrity, team orientation, professionalism, and trustworthiness
Places a high value on ethical standards and treating others with dignity and respect