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Senior Advisor, PBM Regulatory Affairs
at CVS Health
As a Senior Advisor of Regulatory Affairs, you will be responsible for supporting the company's strategic regulatory efforts with a concentrated focus on our Blue Shield of California client. Furthermore, you will also have an opportunity to support other Health Plan and Employer clients, including those in our Exchange and Medicaid lines of business. Also you will have a direct impact on our ability to deliver exceptional state and federal level regulatory support these clients, and will have significant influence in driving clients’ level of confidence in CVS Caremark's ability to administer their plans. As a regulatory subject matter expert, you will be expected to participate in client facing meetings and engagements including educational/informational webinars, and finalists and new client implementation meetings.
This position is responsible for understanding state and federal regulatory requirements for PBM (Pharmacy Benefit Management) related topics such as formulary management, utilization management, prior authorization/appeals, networks, etc. The position requires a deep understanding of state and federal legislative and regulatory bodies, agencies, and processes, including California insurance regulatory agencies. You will collaborate with key business area partners on the analysis and interpretation of regulatory requirements impacting our Commercial, Exchange, and Medicaid clients, and you will work with impacted business owners as a regulatory subject matter expert resource to assist with the evaluation of compliance. You will also participate in discussions regarding system enhancements to ensure legislative and regulatory requirements are understood. The Sr. Advisor should be able to engage in subject matter specific clinical discussions with senior clinical leadership related to topics including medication therapy management, clinical rationale, and the United States Preventive Services Task Force recommendations.
Primary Duties and Responsibilities:
- Provide Medicaid/Exchange/Commercial regulatory support for our Blue Shield of CA (BSC) client though participation in client facing and internal implementation meetings. Support will primarily consist of identifying, summarizing and communicating all relevant statutes and regulations impacting BSC, and will include direct consultation with the BSC compliance team.
- Lead strategic regulatory efforts for Commercial, Exchange, and Medicaid lines of business through interpretation of legislative mandates and regulatory guidance. Be a Subject Matter Expert (SME) offering health care and PBM industry specific knowledge to internal business owners.
- Be an effective influencer to support CVS Health’s various regulatory positions and work with CVS Health Government Affairs team in assisting to influence/shape state and federal regulations (includes participation in regulatory agency and trade group (e.g. AHIP, PCMA) calls and meetings.
- Be able to provide comprehensive market insights for key areas of priority for CVS Health’s Commercial, Exchange, and Medicaid lines of business. Support various business units and the strategic priorities of those business units as appropriate, including the Request For Proposal process.
- 4 years or more of Commercial, Marketplace and Medicaid regulatory, PBM (Pharmacy Benefit Management) experience or a combination of PBM and regulatory experience may be a substitute
- At least 3 years of experience in regulatory compliance
- Minimum of 2 years of experience working with requirements related to the Affordable Care Act and accompanying implementing regulations as they relate to health plan issuers and pharmacy benefits
- Deep knowledge of California regulatory bodies, standards, and process
- Proven skills in strategic thinking and analytical skills, with the ability to diagnose complex problems and recommend practical solutions
- Ability to lead and influence others and to effect change across organizational boundaries, particularly with large employers, health plans (PBM clients), regulatory bodies, and trade associations
- Experience working with clients subject to ERISA and an ability to articulate ERISA requirements
- Ability to exercise professional judgment in analyzing and resolving client issues with little guidance
- Ability to drive to solutions quickly cross-functionally to meet demanding time frames
- Proficient in Microsoft Office Suite with a focus on Excel, PowerPoint, Word, and Outlook
- Proficient in the use of Westlaw
- Excellent verbal and written communication skills (be comfortable and proficient at articulating complex issues to senior level leadership)
- Bachelor’s degree from an accredited college or equivalent work experience
At CVS Health, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, sex/gender, sexual orientation, gender identity or expression, age, disability or protected veteran status or on any other basis or characteristic prohibited by applicable federal, state, or local law. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.