Gerente De Regulaciones Y Monitoreo De Auditoría De Farmacia
Regular
Exempt
GENERAL DESCRIPTION:
Ensures compliance of pharmacy and Pharmacy Benefit Management (PBM) operations with Medicare Part D, Center for Medicaid and Medicare Services (CMS), regulatory, and contractual requirements. Manage audit readiness, monitoring, and Fraud, Waste, and Abuse (FWA) oversight while coordinating audits, regulatory responses, and corrective actions. Partners with internal teams and PBM stakeholders to identify risks, strengthen controls, and ensure accurate and compliant pharmacy operations.
ESSENTIAL FUNCTIONS:
- Manage audit readiness and response activities, including CMS program audits, PBM audits, and internal compliance reviews.
- Designs and executes risk-based audit and continuous monitoring programs aligned with program integrity expectations.
- Interprets and implements regulatory requirements from CMS, Office of the Commissioner of Insurance of Puerto Rico (OCS), Puerto Rico Health Insurance Administration (ASES), and other applicable federal/state agencies, translating them into operational controls and procedures.
- Oversee FWA monitoring efforts, including analysis of Prescription Drug Event (PDE) data, claims data, and pharmacy billing patterns.
- Partner with PBM and other departments to develop and implement corrective and preventive action plans and track remediation through closure.
- Oversees PBM operations and pharmacy network activities to ensure compliance with CMS Part D (Medicare prescription drug benefit program), contractual, and internal policy requirements.
- Coordinates responses to Health Plan Management System (HPMS), CMS communication platform memos, CMS inquiries, and regulatory directives, ensuring timely implementation and documentation of required actions.
- Monitors pharmacy credentialing, training, and First-tier, Downstream, and Related Entities (FDR) compliance, including adherence to CMS training and attestation requirements.
- Reviews and evaluates PBM performance guarantees and pharmacy audits and ensures timely remediation.
- Ensures compliance with coverage determinations, redeterminations, and transition fill requirements, including CMS timeliness and clinical review standards.
- Oversees pharmacy claims operations to ensure compliance with benefit design, formulary rules, and CMS billing requirements.
- Reviews and validates Business Impact Analysis (BIA), regulatory communications, and PBM operational reports, ensuring alignment with CMS expectations and organizational priorities.
- Supervises, monitors, trains, evaluates, and corrects personnel among others to comply with his/her role as a supervisor, to assure that his/her personnel fulfill their work plan and comply with their essential functions and that they behave following the policies, standards, norms, and procedures of the Company.
- Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
- May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.
MINIMUM QUALIFICATIONS:
Education and Experience: Bachelor’s Degree in Healthcare Administration, Health Services Administration, Public Health, Business Administration, or related fields. At least five (5) years of experience in compliance, audit, or regulatory oversight within the healthcare or health insurance industry. Experience leading or supporting CMS Part D program audits, PBM oversight, and regulatory compliance initiatives is strongly preferred. At least two (2) years of experience supervising personnel.
“Proven experience may be replaced by previously established requirements.”
Certifications / Licenses: A valid Certified Internal Auditor (CIA), Certified Healthcare Compliance (CHC), or Certified Fraud Examiner (CFE) certification is preferred. Other: Proficiency in data analysis tools and platforms (e.g., Excel, SQL, and claims reporting systems) is preferred.
Languages:
Spanish – Advanced (comprehensive, writing and verbal)
English – Advanced (comprehensive, writing and verbal)
“We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities.”
