Navitus Health Solutions
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Medicare Part D Oversight Analyst
at Navitus Health Solutions
LocationAppleton Campus: Appleton, Wisconsin
A minimum of a Bachelor's Degree or three years of relevant experience.
3+ years' experience and expertise in audits, facilitating process improvement, reporting, and/or operational monitoring, experience and expertise in Medicare Part D preferred, but not required.
This position is a Medicare Part D SME directly responsible for conducting internal audits and monitoring activities for the PBM Employer Group Waiver Program (EGWP) and selected MA-PD/MMP Health Plan audits. The Med D Oversight Analyst (MOA) will be conduct quality assurance review on all audit and monitoring results. The MOA will be responsible for providing monthly/quarterly audit and monitoring reports to the Medicare Part D Oversight Committee, the Compliance Committee and business partners/clients. The MOA will coordinate Process Improvement Plans (PIPs), as needed. The MOA will be primarily responsible for interfacing with the Plan Sponsor for the EGWP product offering and for collecting and delivering the monthly/quarterly oversight reports, as outlined in the Audit and Monitoring workplan for EGWP. This role requires strong analytical and auditing skills, strong Excel skills and deep knowledge of Medicare Part D rules and regulations.
- Develops and maintains deep subject matter expertise related to Medicare Part D.
- Facilitate review of the processes that support retro-active enrollment changes, changes in LICs status, and member notifications for Employer Group Waver Program (EGWP).
- Coordinate all activities related to the EGWP Data Validation Audit, to include coordination with the third party vendor, collection of all data universes, quality review of all correspondence/data sent to the vendor, and all required reporting.
- Conduct audits on negative formulary changes, to include accuracy of the formulary changes, notices to enrollees, and transition activities.
- Test the accuracy of the formulary administration policy, including transition, by reviewing daily transition monitoring reports, conducting routine audits on formulary rejections and perform trend analysis.
- Review coverage determination processing and evaluate a sample of coverage determinations to ensure they are compliant. Audit a sample of coverage determination letters to verify they contain the appropriate detail informing the member of the decision and next steps.
- Routinely conduct reviews on grievance and appeals processing, notifications and outreach to ensure PBM is consistently performing within the requirements as set forth by CMS.
- Routinely reviews reject management reports to identify trends in rejects. Initiate client communications with impacts for overall issues determined. Support and, if needed, assist with facilitating process improvement efforts identified through the reject management process.
- Assist in the initiation, review and QA of universes and impact analysis reports supporting external CMS audits.
- Assist internal business partners in interpreting audit findings, preparing and completing audit responses, developing corrective actions as appropriate, and monitoring to ensure that corrective actions are successfully implemented. Review and evaluate the effectiveness of corrective action plans and provide comprehensive follow-up to the Medicare Part D Oversight Committee and Compliance Committees.
- Develops, implements, and maintains an audit tracking and documentation system.
- Track, maintain and report on all Med D Performance Improvement Plans (PIP's) and Corrective Action Plans (CAP's)
- Employs a "hands on" approach to issue identification and resolution. Utilizes various tools to proactively monitor data quality.
- Routinely audits P&Ps to departmental performance, ensuring consistency and continuity.
- Other related duties as assigned/required.