Job Closed

This listing is no longer active.

Devoted Health logo
Devoted Health

Devoted Health was founded in 2017 to provide seniors with healthcare plans and personalized health guides using world-class technology. On a mission to make he

Pharmacy Payment Integrity Program Development Lead

Location

United States

Posted

121 days ago

Salary

$100K - $155K / year

Seniority

Lead

Bachelor Degree9 yrs expEnglishCMSSQL

Job Description

Pharmacy Payment Integrity Program Development Lead

Devoted Health

Job Description A bit about this role: At Devoted, we know that one of the most important ways we build trust with our network and members is to pay claims accurately and on time while having transparent payment policies. Our Program Integrity Department ensures that claims are paid correctly by the responsible party, for eligible members, according to contractual terms, not in error or duplicate, and free of fraudulent, wasteful or abusive practices. As the Pharmacy Payment Integrity Program Development Lead, you will serve as the principal strategic owner and hands-on driver of our FWA program within the Medicare Advantage Prescription Drug (MAPD) line of business (Part B and D). You will be responsible for identifying and researching new cost containment and compliance opportunities to improve payment accuracy and mitigate prescription drug fraud, waste, abuse . You will assess new opportunities by leveraging your deep Medicare Part B/ D regulatory expertise, researching and evaluating CMS FWA policies and industry trends, analyzing internal medical and prescription drug claims data, and leading critical cross-functional collaboration . Your Responsibilities and Impact will include: Lead the design and execution of the multi-year strategic roadmap for the Pharmacy FWA program, including vendor utilization, tool enhancements, and scheme prioritization. Proactively and independently analyze  integrated medical and pharmacy data (e.g., medical claims, PDEs, POS pharmacy claims, prior authorizations) to detect patterns of abnormal utilization, high-risk prescriber/pharmacy indicators, and emerging prescription drug fraud schemes. Leverage your deep subject matter expertise, policy research, industry trends, and internal data to generate and prove out novel FWA theories and program concepts that reduce inappropriate prescription drug utilization and claims activity. Partner with and provide insights and recommended actions  to internal teams (e.g., Compliance, Special Investigations Unit (SIU), Clinical, Networks) and the PBM Program Integrity team to address identified claims payment inaccuracies, quantify financial impact, and ensure timely submission of high-quality case leads to the SIU.. Independently create and iterate data sets using advanced query tools to research ideas and develop data insights. Govern the rulesets and algorithms within the third-party FWA analytics platform to maximize high-yield case detection. Prepare and present regular reports to Executive Leadership on program ROI, regulatory risk exposure, net recoveries, and the strategic direction of the Pharmacy FWA program. Required skills and experience: Bachelor's degree and a minimum of 6+ years of progressive experience in Pharmacy Benefit Management (PBM), Managed Care, or Health Plan FWA/Payment Integrity, with a primary focus on the Medicare Part B/D prescription drug regulatory environment. Expert-level knowledge of Medicare Part B/D claims processing and CMS FWA requirements (42 CFR 423 Subpart K). Salary range: $105,000 - $155,000 annually The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job. Our Total Rewards package includes: Employer sponsored health, dental and vision plan with low or no premium Generous paid time off $100 monthly mobile or internet stipend Stock options for all employees Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles Parental leave program 401K program And more.... *Our total rewards package is for full time employees only. Intern and Contract positions are not eligible. Healthcare equality is at the center of Devoted’s mission to treat our members like family.  We are committed to a diverse and vibrant workforce. At Devoted Health, we’re on a mission to dramatically improve the health and well-being of older Americans by caring for every person like family. That’s why we’re gathering smart, diverse, and big-hearted people to create a new kind of all-in-one healthcare company — one that combines compassion, health insurance, clinical care, service, and technology - to deliver a complete and integrated healthcare solution that delivers high quality care that everyone would want for someone they love. Founded in 2017, we've grown fast and now serve members across the United States.  And we've just started. So join us on this mission! Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business. As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.

Job Requirements

  • Strong communications skills (verbal, written, presentation, interpersonal) with all types/levels of audience, including the ability to articulate complex FWA findings to executives.
  • Ability to multitask, effectively prioritize critical tasks, and drive outcomes across cross-functional teams without direct reporting authority.
  • Ability to understand, explain, and break down complex problems related to regulatory compliance and pharmacy claims processing.
  • Desired skills and experience:
  • Clinical credentials (e.g., Pharmacist, CPhT).
  • Experience working with or overseeing PBM program integrity vendors, analytics platforms, or investigative case pipelines; experience with RxShield is a plus.
  • Prior involvement in CMS audits, ODAG/DAG reviews, MEDIC referrals, or PBM compliance monitoring.
  • Expert proficiency in querying large datasets using SQL
  • #LI-Remote
  • #LI-DS1

Related Categories

Related Job Pages

More Business Development Rep Jobs

OtherRemoteTeam 1,001-5,000H1B Sponsor

Ameris Bank is a purpose-driven company, dedicated to bringing financial peace of mind to communities, one person at a time. Whether a customer wants to grow their business, buy a home, or feel confident in their retirement plan, they have a partner in Ameris Bank. We serve customers in our locations across the Southeast, Mid-Atlantic and nationwide through our extensive digital offerings and mobile app. Delivering financial peace of mind starts with a team that values integrity and rewards ingenuity. At Ameris, you’ll find teammates who are inclusive, collaborative problem-solvers who go the extra mile to support one another and to meet every customer’s needs. When teammates are empowered and bring their diverse perspectives to the table, we create the best possible outcomes for our customers. At Ameris, we know that a growth mindset is key for high performance and fosters an environment that prioritizes continuous improvement. Teammates have access to Employee Resource Groups that serve as advocates and purpose and how you can bring it to life as an Ameris Bank teammate. The GGL Business Development Officer will be responsible for the prospecting, sourcing and origination of a variety of SBA 7a, SBA 504, and USDA B&I loan opportunities in compliance with the bank’s policies, eligibility standards, and federal regulations. Perfroms other projects and duties as assigned. Essential Functions, Duties and Responsibilities - Originate compliant loans and perform the various related activities, including cold calling prospective borrowers, establishing relationships with referral sources, and participating in events. - Responsible for achievement of goals as set by the bank’s leadership. - Demonstrate effective sales strategies and techniques to attract, expand, and retain customer relationships. - Educate prospective borrowers/referral sources regarding the bank’s loan programs. - Evaluate the creditworthiness of potential borrowers. - Responsible for loan structuring, eligibility, financial analysis, and the preparation of the credit package. - Manage client expectations and provide guidance regarding the flow of the GGL loan process. - Serve as the client’s primary point of contact from application to closing. - Assist Underwriting, as needed, in the due diligence process. - Maintain knowledge of banking products, programs, services, and promotions. - Ensure compliance with internal controls, operational procedures, and risk management policies. - Develop partnerships and collaborate with other lines of business to achieve mutual goals and better serve customers. - Practices ethical sales behaviors in accordance with Ameris’ core values of Integrity and Honesty; always acts in the best interest of the customer when offering additional products and services. Required Knowledge, Skills and Competencies - Ability to identify prospects. - Ability to be consultative in the sales process. - Ability to be flexible and react swiftly to changes and adjusting priorities. - Driven to meet and exceed established annual loan production goals. - Ability to effectively communicate verbally and in writing, using language and grammar in a professional manner. - Solid understanding of financial statements, tax returns, and credit reports. - Ability to establish and organize a professional schedule in order to achieve strategic goals within established time frames. - Ability to manage multiple loan applications simultaneously. - Ability to effectively interact at all levels, building relationships and addressing identified needs. - Proficiency in Microsoft Word, Excel, and software used for spreading financial information.. - Working and/or conceptual knowledge of government guaranteed lending products (SBA and USDA) and the SBA SOP. - Thorough knowledge of banking policies, procedures, products, and services. - Proficiency in CRM systems and loan origination software. Industry and Work Experience - Minimum of 3 years of commercial loan origination and/or Government Guaranteed Lending experience required. - Successful business development, sales, or related experience required. Academic - Bachelor’s degree in Business, Finance, or related field required. Salary range (DC): $113,215 - $189,068k per year Benefits Available to Employees: Ameris Bank provides a comprehensive employee benefit package to all eligible employees. - Medical, Dental and Vision Insurance - Ameris Bank absorbs a major portion of the cost of healthcare. You become eligible for coverage on the first of the month following 30 days of employment - Life Insurance provided at no additional cost to employees - Accidental Death & Dismemberment Coverage - Long-Term Disability Coverage - Paid Sick and Vacation Leave - 11 Holidays - Volunteer/Service Day - Employee Stock Purchase Plan - 401(k) Retirement Plan - Ameris Bank matches 50% of your first 8% of contributions to the plan - Flexible Spending Accounts - Health Savings Account - Health Reimbursement Arrangement - Supplemental Life & Other Insurance Plans - Identity Theft Protection - Pet Insurance - Legal Insurance - Employee Assistance Program - Employee Advocacy Program - Tickets at Work (Entertainment discounts for Ameris Bank Employees) - AT&T Employee Discount - Wellness Discounts for Medical Premiums and Other Rewards - Employee Referral Incentive - Education Assistance - Employee Resource Groups Banking Advantages for Employees: In addition to a wide array of benefits, Ameris Bank employees are also eligible for special bank services. - Free Interest Checking - Free Safe Deposit Box - Free Money Orders, Travelers’ Checks and Cashier Checks - Discount on Mortgage Origination Fee - Free Online Banking and Free Unlimited Online Bill Payment - Employee Banking Perks Disclaimer: The above job description is meant to describe the general nature and level of work being performed; it is not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required for the position. All job requirements are subject to possible modification to reasonably accommodate individuals with disabilities. Some requirements may exclude individuals who pose a direct threat or significant risk to the health and safety of themselves or other employees. Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities This employer is required to notify all applicantss of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.

United States
$113K - $189K / year
Job Closed
Capital Impact Partners logo

Business Development Officer

Capital Impact Partners

Building Communities of Opportunity That Break Barriers To Success

OtherRemoteTeam 51-200Since 1982H1B No Sponsor

• Market and promote Capital Impact Partners’ Community Development Lending products to real estate and small business prospects, community lenders, community partners, and other financial institutions across our core markets in the DC Metro, NYC Metro, and Detroit Metro Areas • Identify, foster, and maintain relationships with partners, borrowers, prospects, and other community stakeholders within our sectors and across the aforementioned markets • Manage CDL loan pipelines in the Eastern Region, specifically in the DC Metro, NYC Metro, and Detroit Metro Areas • Respond to all CDL loan inquiries in the Eastern Region in a timely manner • Present to groups, engage with individuals, and positively represent Momentus at conferences, webinars, groundbreakings, and other business and industry functions • Monitor market trends and opportunities • Gather data (both qualitative and quantitative) about product and service offerings and identify areas for improvement • Assist with the development and implementation of products, services, and special initiatives within assigned markets • Help coordinate information sharing and collaboration across Momentus teams in the Eastern Region • Demonstrate a firm understanding of the entire Momentus Capital loan suite of products and services and collaborate with other Momentus capital deployment teams on cross-marketing opportunities and optimizing financing solutions and customer experiences • Assist Marketing and Communications team in producing communications about our lending and impact in assigned markets • Ensure that communications and promotional materials remain accurate and up to date • Assist Compliance team in reporting to funders and investors on specific lending programs in assigned markets • Support Fundraising team in preparing and responding to grant applications and request for proposals • Identify, meet, and screen potential borrowers and their community development projects • Establish clear and appropriate expectations with prospective borrowers through discussion and explanation of lending products, programs, and processes • Pre-screen, compile, structure, and analyze loan applications for eligibility, credit worthiness and repayment ability using established credit policy and underwriting guidelines • Provide business history, management, loan purpose and eligibility narrative within loan processes • Determine loan eligibility based on any geographic, impact, or business strategy specific requirements • Determine credit worthiness based on review of cash flow and credit history and ensure prospects will meet basic credit criteria • Identify major risks and other considerations to assist credit approvers in making loan decisions • Perform preliminary loan structuring, propose terms, and secure preliminary approval from lending and credit approvers to proceed to underwriting • Prepare Letters of Interest and/or Term Sheets, communicate proposed terms to prospective borrowers, and negotiate terms as appropriate • Manage smooth transition of loan prospects to Loan Officers and/or Underwriters • Work with Loan Officers, Underwriters, and other team members to help resolve relationship, loan structuring, and credit challenges that may arise with transactions in the Eastern Region • Assist with loan screening in other geographic markets on an as-needed basis • Assist with credit memos on an as-needed basis

New York + 2 moreAll locations: New York | Michigan | Virginia
$98.8K - $145K / year
Job Closed
Cynet Group logo

Director of Sales & Business Development (Locum Tenens)

Cynet Group

Global Workforce Solutions Across Healthcare, IT & Physician Staffing

OtherRemoteTeam 1,001-5,000Since 2010H1B No Sponsor

Join an award-winning and talented organization that delivers world-class healthcare workforce solutions. Working within a vibrant and passionate team of recruitment and sales professionals you will bring your energy and thrill of the hunt that will fuel our growth by generating a sales pipeline for our Locum Tenens division. About the Role: The Director of Sales & Business Development is a key position, with the dual responsibility of acquiring new business and growing a portfolio of acquired regional and national Healthcare accounts in a clinical setting, serving acute care hospitals, outpatient and ambulatory-care centers, skilled nursing facilities, large corporations onsite clinics, rehabilitation, and sports medicine clinics, and government healthcare bodies.  What will you be doing day to day? - Develop and implement an effective sales plan to meet or exceed sales objectives in acquiring new clients - Develop relationships with key decision-makers at direct facilities for all staffing needs and partner with them on filling their needs exclusively  - Perform prospect visits to hospitals and other facilities to educate and inform on our staffing services and drive exclusive and set-aside business for the company. - Managing client relationships to generate referrals as well as grow current accounts - Help recruiters by relaying exact customer needs and opportunities to them - Reverse market Physicians and APPs to all clients in the portfolio - Maintain a healthy P&L by processing quality submittals and making placements - Monitor customer satisfaction regularly through quality metrics and client scorecards - Attend community networking events to create additional business relationships - Keep abreast of trends in the industry and identify new opportunities for the growth of your portfolio Your Experience: - Extensive Sales and Business Development experience in acquiring new business - Extensive experience in the Locum Tenens and Advance Practice Staffing - Great attitude, passion, and drive to be a perfectionist - High-energy and competitive nature that seeks results and personal accountability Your Skills: - Act as a healthcare industry expert and advisor - Strong relationship-building skills - Exceptional planning and execution skills - Exceptional customer service skills - Ability to work in a fast-paced, competitive environment About Cynet Locums: Headquartered in the Washington, D.C. metro area, Cynet Locums is a NALTO-affiliated Workforce solutions company that helps our clients realize their talent potential through custom staffing & recruiting solutions. For more information, please visit our website, www.cynetlocums.com

United States
VALD logo

Business Development Manager

VALD

World leaders in musculoskeletal technology for performance, allied health, and tactical professionals.

OtherRemoteTeam 51-200H1B No Sponsor

• Own and manage a defined sales territory across performance and health verticals • Self-generate a sales pipeline through outbound prospecting and marketing driven inbound opportunities • Conduct in-person and virtual product demonstrations & oversee client trials • Work full-cycle sales opportunities in partnership with Contracts and Client Success • Achieve monthly and quarterly quota targets based on quantity of systems sold • Accurately manage pipeline activity using CRM tools (HubSpot experience is a plus) • Represent VALD professionally at conferences, events, and industry meetings

Florida
Job Closed