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Part-Time Senior Consultant: Coverage Determinations, Appeals and Grievances

Job Summary:

Responsible for providing subject matter expertise on Coverage Determinations, Appeals and Grievances (CDAG) in order to effectively support our clients and internal consultants.

Essential Functions:

  • 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.

Qualifications:

  • 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.

 


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Part-Time Senior Consultant: Coverage Determinations, Appeals and Grievances

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