Manager – PBM Licensing & Regulations

AnewHealth is one of the nation’s leading pharmacy care management companies that specializes in caring for people with the most complex, chronic needs—wherever they call home. We enable better outcomes for patients and the healthcare organizations who support them. Established in 2023 through the combination of ExactCare and Tabula Rasa HealthCare, we provide a suite of solutions that includes comprehensive pharmacy services; full-service pharmacy benefit management; and specialized support services for Program of All-Inclusive Care for the Elderly. With over 1,400 team members, we care for more than 100,000 people across all 50 states.

Job Details

The Manager, Pharmacy Benefits Regulatory Operations is responsible for regulatory oversight of Pharmastar. This position also assists with various internal tasks that ensure a high level of overall client compliance and satisfaction.

Pharmastar (a Tabula Rasa HealthCare Group company) is a Pharmacy Benefits Manager (PBM) for commercial plans, Medicare Part D Plans and PACE Plans.

Responsibilities

• Oversee PBM Licensing – ensures Pharmastar is appropriately licensed based on services rendered.

• Track state and federal business requirements and manages compliance with associated regulatory reporting.

• Contact regulators for clarification and guidance as necessary.

• Manage regulatory audit proceedings.

• Coodinate pharmacy audits and distributes plan specific audit result letters. 

• Participate in clients’ CMS financial audits providing documentation and reports as needed.

• Research regulatory issues as it relates to clients’ drug benefits and report results to clients.

• Develop Corrective Action Plans (CAPs) in response to audit findings.

• Monitor Medicare Part D regulation and guidance for applicability to Pharmastar. Assists with facilitating client awareness of regulatory changes.

• Responsible for maintaining P&P related to the regulatory compliance of Pharmastar includes drafting and editing.

• Provide guidance to the Pharmastar regulatory team, including training and development.

• Communicate with staff regarding needs of both the client and the company. Follow up to ensure appropriate action is taken in a timely fashion.

• Monitor client utilization and proactively solve issues as they arrive.

• Research regulatory issues as it relates to clients’ drug benefits and report results to clients.

• Assure departmental compliance with company policies, procedures, standards and regulatory requirements.

• Promote staff enthusiasm and teamwork, support others in their job functions.

• Ensure that HIPAA guidelines are followed in every communication with clients.

• Stay current on plan and benefit structures, pharmacological updates, and Medicare Part D guidelines.

• Attend department and company meetings and educational programs upon request.

• Other related duties as assigned.

Qualifications

These represent the desired qualifications of the ideal candidate. They are not meant to limit consideration for candidates who do not meet all of the standards listed. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.  

Education:

• Required: 

  • Associate's degree or related experience.

Experience:

• Required: 

  • Minimum of 5 years of healthcare experience. 

  • Knowledge of Medicare Part D Plan and/or PACE Administration

  • Experience in PBM or pharmacy support role.

  • Current on plan and benefit structures and Medicare guidelines.

Skills & Abilities:

• Required: 

  • Drives a strong culture of owning problem solving and accountability.

• A forward-thinking personality capable of identifying areas for improvement.

• Outstanding written and verbal communication skills with clarity of thought and the ability to express, advocate and defend views effectively.

• Skilled in establishing and maintaining effective working relationships with clients, customers, and staff at all levels.

• Skilled in problem resolution; recommends suggestions to increase accuracy and/or efficiency.

• Ability to continuously display personal integrity and exemplary ethical standards.

• Tolerance for, and the ability to perform well, in stressful and ambiguous situations.

• Ability and flexibility to work in a relatively unstructured environment in a rapidly growing, dynamic company.

• Maintains safe working environment. Follow all Policies and Procedures and OSHA safety guidelines.

• Strong computer skills including using word processors, spreadsheets, and database software.

Schedule

• Schedules are set to accommodate the requirements of the position and the needs of the organization and may be adjusted as needed. 

Travel

• Travel may be required for special department events, trade shows, or conferences.

AnewHealth offers a comprehensive benefit package for full-time employees that includes medical/dental/vision, flexible spending, company-paid life insurance and short-term disability as well as voluntary benefits, 401(k), Paid Time Off and paid holidays. Medical, dental and vision coverage are effective 1st of the month following date of hire.

AnewHealth provides equal employment opportunity to all qualified applicants regardless of race, color, religion, national origin, sex, sexual orientation, gender identity, age, disability, genetic information, or veteran status, or other legally protected classification in the state in which a person is seeking employment. Applicants are encouraged to confidentially self-identify when applying. Local applicants are encouraged to apply. We maintain a drug-free work environment. Applicants must be eligible to work in this country.