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Senior Regulatory Specialist

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Healthfirst

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Location:
United States

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Category:
IT - Administration

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Contract Type:
Employment contract

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Salary:

73100.00 - 120360.00 USD / Year
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Job Description:

The Senior Regulatory Specialist – Pharmacy is responsible for promoting compliance with regulatory requirements within Healthfirst's Pharmacy and Dental departments and/or delegated vendors. Compliance is promoted by ensuring regulatory updates are evaluated and properly implemented, along with performing monitoring to evaluate compliance with regulatory requirements required by Centers for Medicare and Medicaid Services (CMS) and State Department of Health (DOH) regulations, and business requirements. The role also entails supporting the maintenance and oversight of the Restricted Recipient Program (RRP).

Job Responsibility:

  • Monitor incoming regulations including those received from Centers for Medicare and Medicaid Services (CMS), State Department of Health (DOH), Office of Medicaid Inspector General (OMIG) and other channels
  • Share regulatory guidance with Pharmacy department and provide support to ensure regulation and impact are understood
  • Act as a liaison between Pharmacy Department and Regulatory Affairs/Legal when guidance on interpretation is required
  • Provide support to Pharmacy Department related to regulatory implementation efforts including: Tracking deliverables to target, Coordinating meetings and collecting deliverables from business units, Capturing action steps, Communicating to leadership
  • Coordinate monthly meetings with the RRP review team and in collaboration with other departments
  • Support all RRP committee meetings and be responsible for documenting attendance and monthly meeting minutes
  • Data analysis of pharmacy and medical claims data to identify potential candidates for RRP
  • Review claims reporting to identify inappropriate fraud, waste, and abuse trends resulting in referral for review by the RRP committee for potential restriction
  • Participate in monthly OMIG meetings and subsequently meet with internal stakeholders to review determine actionable items
  • Manage and maintain proper documentation of the RRP roster
  • This includes managing referrals from OMIG, members transitioning into the plan under previous MCO or fee for service (FFS) restriction and ensuring timely reviews of members up for re-restriction are being conducted
  • Also includes maintaining detailed summary reviews, determinations, and appeals associated with member
  • Process new enrollee RRP notices to new members joining the plan with restrictions under a previous MCO or FFS
  • Process provider notifications when a provider is designated as a member’s restricted provider
  • Process restriction change requests from members, OMIG, and DOH
  • Conduct monthly, quarterly, and annual monitoring for the processes of RRP to reduce compliance risks
  • Triage RRP Inbox requests and prioritize tasks based on urgency, importance, and service level agreement (SLA)
  • Process Fair Hearing requests within one business day of receipt
  • Assist with state audits, with data analysis of pharmacy and medical claims data
  • Identify process gaps or process improvements and collaborate with Pharmacy department and other business units to implement process enhancements
  • Creating comprehensive corrective action plans
  • Attend Regulatory, Pharmacy and departmental meetings, as deemed appropriate
  • Additional duties as assigned

Requirements:

  • High School Diploma or GED from an accredited institution
  • Working knowledge of CMS and state regulatory requirements

Nice to have:

  • Bachelor's degree from an accredited institution
  • Knowledge of regulations of Medicaid Services and the New York State Department of Health
  • Managed Care experience
  • Pharmacy experience
What we offer:
  • medical, dental and vision coverage
  • incentive and recognition programs
  • life insurance
  • 401k contributions

Additional Information:

Job Posted:
May 09, 2026

Employment Type:
Fulltime
Work Type:
Remote work
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