Manager, Pharmacy Compliance

Overview

SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation's leading not-for-profit Medicare Advantage plans, serving more than 277,000 members in California, Arizona, Nevada, Texas and New Mexico. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 45 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare.

SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts.

If you are interested in becoming part of an organization that is innovating senior healthcare visit (Use the "Apply for this Job" box below). , or follow us on Linked In, Facebook, and Twitter.

Job Description:

This position will play a central role in designing and executing the Part D program for coverage determinations, appeals, and grievances for a senior-focused Medicare Advantage Plan. The Supervisor will be responsible for ensuring CMS compliance with regard to operations, star rating performance, and enhanced member/provider experience, and will also provide leadership support and direction to the team, ensuring appropriate oversight of the contracted pharmacy benefit manager (PBM).

• Lead and support CMS Part C and D Program Audits, Data Validation Audits, manage Universe Files, oversee HPMS reporting (CDR, IDUC, Appeals, Grievances), and monitor audit preparedness through mock audits and post-submission review.
• Supervise the Pharmacy Experience & Access team to oversee and optimize PBM delegated programs (concurrent DUR, retro
  
  DUR, FWA, Patient Safety Analysis, Opioids) for compliance and effectiveness.
• Ensure CDAG operations (coverage determinations, appeals, grievances) are timely, compliant, and effective, preventing ICARs, CMPs, and data accuracy issues.
• Implement process enhancements that strengthen compliance, efficiency, and member experience through routine tracking and trending.
• Maintain up-to-date clinical policies and SOPs, ensuring internal adherence across clinical operations.
• Serve as subject matter expert for Part D coverage determinations, redeterminations, grievances, and Part C organization determinations.
• Stay current with Medicare Part D regulations by attending CMS calls and applying released guidance to maintain compliance.
• Oversee PBM operations, collaborating on process improvements and CMS updates to support quality performance and enhance member experience.
• Provide supervision, development, and coaching to pharmacists, technicians, and support staff, fostering a culture of process improvement, operational excellence, and compliance.
• Act as Residency/APPE Director, setting expectations, appraising performance, and supporting student/resident pharmacists and their preceptors.
• Supervises/Manages Others (i.e. hires, performance reviews, corrective action, etc.).
• We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.
• Actively support the achievement of SCAN s Vision and Goals.
• Other duties as assigned.

• Bachelor s Degree required. PHARMD or equivalent.
• Required Certifications or Licenses:
  Pharmacists (PHs)
• Completion of a PGY1 and/or PGY2 residency or equivalent clinical practice experience.
• Demonstrated knowledge of and experience monitoring Medicare Part D regulations, required.
• 5+ years or more of managed care pharmacy experience; or equivalent experience in a managed care setting, strongly preferred.
• 1-2 years leadership/management experience strongly preferred.
• Knowledge and experience with organizing quality improvement initiatives and presenting findings to leadership.
• Previous experience in precepting and mentoring pharmacy students and residents is desirable.
• Leadership - Lead and inspire teams to achieve performance goals, offering guidance and support
• Problem Solving - Good problem-solving skills
• Communication - Good communication and interpersonal skills
• Strong analytical, problem-solving, and decision-making abilities - Ability to think strategically while executing tactically - Detail-oriented and highly adaptable to a fast-paced, evolving environment - Demonstrated ability to manage multiple priorities simultaneously
• Proven leadership, supervisory, and accountability skills - Strong organizational, time management, and project management capabilities - Self-starter with a resourceful and innovative mindset - Effective across cross-functional teams and collaborative environments
• Exceptional verbal, written, and…