Pharmacy Compliance Specialist

Central Coast Salary Range: $76,466 - $110,875 Annually

Job Summary

The Pharmacy Compliance Specialist is responsible for ensuring that an department adheres to regulatory and contractual requirements, as well as internal policies and procedures. They assess risks, support development of the Pharmacy Teams compliance oversight, and provide guidance to pharmacy management and staff on compliance-related matters. The Pharmacy Compliance Specialist is responsible for ensuring accurate, high quality, and timely submissions of required regulatory reports and submissions to pharmacy leadership.

Duties and Responsibilities

Regulatory Compliance

•Monitors, reviews, analyzes, interprets, and summarizes new or revised federal and state regulatory requirements applicable to CenCal Health’s Dual Special Needs and Medicaid lines of business.

•Ensures as part of implementation of new or revised regulatory requirements, business leaders revise or create policies and procedures that reflect requirements and changes in operations.

•Ensures CenCal Health pharmacy policies align with state and federal laws, regulations, and guidance applicable to the Dual Special Needs and Medi-Cal line of business.

•Supports maintenance of a summary requirements crosswalk detailing Medicare Advantage, Medicare Part D, and Dual Special Needs Plan requirements in comparison to Medicaid requirements.

•Ensures Dual Special Needs pharmacy member communication and marketing materials align with state and federal regulations and guidance, provides guidance to business leaders regarding development of member materials, maintains a tracking log of member materials, and submits applicable member materials to CMS, DHCS, or DMHC for review, as required.

•Supports maintenance of a pharmacy department policy and procedure library.

•Mentors junior team members and provides training regarding Medicaid, Medicare, Medicare Advantage, Medicare Part D, and Dual Special Needs Plans, fostering a collaborative and growth-oriented team environment.

Regulatory Reporting and Submissions

•Supports the department leadership in the preparation of accurate, high quality, and timely submissions of both ad hoc and routine regulatory reports and submissions to regulatory agencies.

•Supports the development of internal processes to facilitate the timely submission of regulatory reports and submissions.

•Coordinates with departmental leadership to prepare documents, reports, and other key deliverables required for regulatory reporting and submissions.

•Ensures records and documentation of submitted reports and submissions are well catalogued and complete.

•Supports the development and maintenance of a regulatory reporting and submissions calendar, including all reports and submissions required.

•Other duties, as assigned.

Knowledge/Skills/Abilities

•  Understanding of regulatory or compliance processes impacting managed health care, Medicaid and 
Medicare.
•  Understanding of basic principles of Medicaid and Medicare to include Medicare Advantage and 
Medicare Part D.
•  Understanding of the managed health care model.
•  Understanding of federal and state regulatory agencies and processes.
•  Understanding of CenCal Health’s operations and processes a plus.
•  Ability to facilitate discussions and deploy action requests to large cross functional 
groups.
•  Demonstrate excellent problem-solving skills and analytical skills with high attention to 
detail.
•  Demonstrate success in a collaborative culture, including the ability to navigate different 
working styles and priorities across teams.
•  Demonstrate process improvement experience and a growth mindset.
•  Ability to effectively prioritize multiple tasks and deadlines.
•  Ability to assume responsibility and exercise good judgment in making decisions within the scope 
of authority of the position.
•  Ability to handle sensitive information with confidentiality and integrity.
•  Ability to communicate accurately and effectively, both orally and in writing.
•  Ability to establish and maintain effective and cooperative working relationships with 
management and staff.
•  Ability to work under pressure to accurately complete tasks within established 
deadlines.
 

Education and Experience

•  Must have at minimum 5 years’ experience in the health care field (preferably in a
managed care setting).
•  Must have at minimum a Bachelor’s Degree in a related field. An additional 4 years’ experience 
may be accepted in lieu of a Bachelor’s Degree.
•  Must have experience and knowledge with Medicare Advantage and Medicare Part D requirements, 
reporting, and submissions; and working with federal and state regulatory agencies, including but 
not limited to, CMS and the Office of Inspector General (OIG).
•  Must have experience with reviewing, understanding, analyzing, interpreting, and summarizing new 
laws and regulations or changes in laws and regulations.
•  Must have experience researching, compiling and organizing information from various 
sources.
•  Must have knowledge of and proficiency in the use of Microsoft Office Suite, including, Word, 
Excel, PowerPoint and SharePoint, as well as SmartSheets.
•  Must have attention to detail and accuracy.
•  Must have time and/or task management experience, and the ability to prioritize tasks (project 
management experience is a plus).
•  Must have experience in the creation, preparation, and presentation of reports and 
presentations.
•  Comfortable with learning to use new computer systems as necessary to support Compliance 
programs.
•  Pharmacy Technician License.