Job Title: Compliance Specialist – CMS (Center of Medicare/Medicaid Service)
We specialize in healthcare management technology and offer a suite of utilization management software solutions for our clients. Our mission is dedicated to improving the quality of care and expediting the delivery of health care services by advancing and automating utilization management processes. We are based in Parsippany NJ, with clients across the United States. As we grow, we are looking for a detail- oriented, self-motivated, independent individual to manage CMS compliance around utilization management and formulary management.
The Agadia Systems’ CMS (Center of Medicare/Medicaid Service) Coordinator, assists in all aspects of regulatory reporting and tasks that assist with maintaining compliance in accordance with federal and state laws and regulations, accreditation standards, and company policies and procedures. This person works closely with different team members and assures seamless execution and customer satisfaction. Must be able to stay current on regulations and changes that CMS publishes for final rules and even proposed rules.
- Management or Business Degree Preferred
- Certified Pharmacy technician or Nursing degree with pharmacy experience preferred
- Experience in Clinical programs/services: MTM, Transitional Care, Medication Synchronization, Drug Management Program, Medication Reconciliation, and/or Specialty Pharmacy Reconciliation, and/or Specialty Pharmacy
- Understanding of CMS/Regulatory/Compliance requirements (CDAG/ODAG/ODR/CDE)
- Minimum of 3+ years of relevant experience in Compliance Management
- Able to Travel to customer sites: minimal (1-2 times per year each client)
- Experience in Medicare Part B & Part D
- Able to work with, all levels of leadership to oversee and ensure the compliant implementation.
- Accountable for CMS reporting compliance for clients (CDAG/ODAG/ODR/CDE).
- Serves and the lead in CMS audit activities and audit readiness reviews.
- Provide guidance in order to obtain and/or maintain compliance with State & Federal regulations.
- Review all plan policies and procedures for compliance with program requirements prior to submission of documents for RFP process.
- Educate various departments on the process and procedures in submitting marketing materials for state and federal review.
- Supports in creating and updating monitoring metrics to assess continued compliance with regulatory requirements
- In-depth knowledge of the healthcare industry; fraud, waste and abuse audit operations, and claims handling and payment operations.
- Ability to interact with others in one-on-one situations to identify issues/problems and provide training/coaching to correct problem areas.
- Other duties as assigned or requested
- Strong verbal and written communication skills
- Strong presentation and public speaking skills.
- Familiar with utilization management processes
- Problem solving and business analysis skills with strong attention to detail
- Ability to explain information clearly and simply
- Strong execution skills
- Highly organized and flexible
- Ability to establish and maintain effective and constructive working relationships with others, both internal and external to the organization
- Ability to work independently and in a team environment
- Ability to work on different projects within the same timeframe
- Adept at project management to drive issues to resolution
- Possess drive, initiative and motivation
- Communicates effectively– Attentively listens to others, provides timely and helpful information and is effective in a range of professional settings. Gives and receives feedback in a productive, professional manner. Demonstrates excellent oral and written communication skills.
- Manages Ambiguity –Operating effectively, even when things are not certain, or the way forward is not clear. Is flexible in approach and is able to adapt their approach to meet changing business needs.
- Manages complexity –Makes sense of complex, high quantity, and sometimes contradictory information to effectively solve problems. Has strong organizational skills and is able to manage multiple activities at once. Has high attention to detail.
- Ensures Accountability –Follows through on commitments and makes sure others do the same. Able to work independently as part of a team.
Please send your resume & cover letter to firstname.lastname@example.org