Remote Utilization Review Manager Jobs in Seattle, WA

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us.

Job Posting TitleRegulatory Analyst (Remote)Job DescriptionThe Regulatory Analyst is responsible for leading portions of regulatory assessment, external audits and accreditation processes within the Commercial, Medicare, Medicaid, and Health Insurance Marketplace for the assigned department. This position is responsible for primary point of contact for internal and external business partners regarding related regulatory activity and quality efforts involving utilization and/or medication therapy management, client delegation agreements and accreditation entities, SOP development and maintenance.

Responsibilities

• Participate in portions of external audits as directed by the Centers for Medicare & Medicaid Services (CMS), Medicaid, NCQA, participate in commercial and Client driven external audits, annual reviews, and pre-delegation reviews and lead assigned department (i.e. Clinical Operations, PBM Operations) portions of ongoing Accreditation processes
• Assist in Regulatory Review Committee Meetings, Healthcare Reform Meetings, Regulatory Oversight Meetings, CMS User Calls, and Government Programs Compliance Committee Meetings to monitor new regulations and provide necessary updates to these committees
• Lead the Client, external auditor, and/or accreditation reviewer through Prime's business processes and provide the appropriate documentation and/or data files as they relate to accreditation standards or regulations
• Maintain regulatory and accreditation gap status reporting to keep all constituencies informed; track, manage, and report on work stream status against plan
• Lead all efforts for response to inquiries related to the assigned department, which may include pulling pertinent case files/samples, validating regulatory requirements, and review and validation of processes against requirements
• Take lead on change management related to regulatory requirements
• Other duties as assigned

Minimum Qualifications

• Bachelor's degree in business, finance, health services or related area of study, or equivalent combination of education and/or relevant work experience

• 3 years of PBM, healthcare, and/or compliance work experience
• Must be eligible to work in the United States without need for work visa or residency sponsorship

Must be eligible to work in the United States without the need for work visa or residency sponsorship

Additional Qualifications

• Strong verbal and written communication skills
• Demonstrated critical thinking and analysis skills with the ability to interpret regulations into operational requirements
• Strong attention to detail and commitment to meeting established timeliness

Preferred Qualifications

• Demonstrated knowledge of CMS regulations and Health Care Reform and extensive knowledge of clinical review and/or medication therapy management processes/procedures
• Proficient in standard software (Word, Visio, and Excel)

Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures

Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job.

Potential pay for this position ranges from $66,000.00 - $106,000.00 based on experience and skills.

To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits at a glance" button for more detail (https://www.primetherapeutics.com/benefits).

Prime Therapeutics LLCis proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law.

We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law.

Prime Therapeutics LLC is a Tobacco-Free Workplace employer.

Positions will be posted for a minimum of five consecutive workdays.