Part-Time Senior Consultant: Coverage Determinations, Appeals and Grievances
Responsible for providing subject matter expertise on Coverage Determinations, Appeals and Grievances (CDAG) in order to effectively support our clients and internal consultants.
- Subject matter expertise in Part D Coverage Determinations, Appeals and Grievances (Chapter 18).
- Ability to review, interpret and implement state and federal guidance.
- Perform CMS mock audits in CDAG to confirm compliance with guidance.
- Monitors the implementation of the corrective action plans and ensures that the results of the action plans are compliant.
- Mentor and drive work product based on the project.
- Oversee and administer ongoing monitoring program(s) based on guidance.
- Updates policies, procedures and Audit Work Plans as needed.
- Adhere to established corporate policies and procedures.
- Perform other duties, as necessary, to meet corporate objectives.
- Travel as required.
- Bachelor’s degree and a minimum of ten (10) years government, health care, pharmacy benefit management, compliance or quality profession required (equivalent combination of education and experience considered.)
- Previous employment at a health plan or pharmacy benefit manager required.
- Must have strong Microsoft Office Suite skills. Advanced skills in Word, Excel, Access and PowerPoint required.
- Experience with Medicare standards required.
- Advanced degree or certification in audit, pharmacy or compliance discipline preferred.
- Must have strong verbal and written communication skills.
- Individual should be detail oriented with strong organization, prioritization and analytical skills with the ability to work independently.
- Must work well under tight timelines and adapt quickly to change in a fast-paced, team-oriented, and high-growth environment.
- Must have strong customer service skills.