What you’ll do

In a few words…

Abarca is igniting a revolution in healthcare.  We built our company on the belief that with smarter technology we are redefining pharmacy benefits, but this is just the beginning…

The Legal & Compliance department ensures our business operations and processes are compliant with all state and federal requirements. They keep Abarca updated on all regulatory and legislative developments to mitigate impact on the services we offer! They're also the team we go to for channeling services from our external legal counsel and working on matters related to tax, audits, managing codes of conduct as well as corporate, and healthcare law.

As our Senior Compliance Auditor, you will be responsible for ensuring successful completion of assigned audit engagements set forth in the company’s Audit Plan with the delegated entities. You will manage and carry out operational audit activities as assigned. You will also be responsible for any external audits including Abarca’s delegated entities. In this position you are also responsible for applying audit & monitoring techniques to examine documentation, interview employees, and conduct analysis of data to identify deficiencies and best practices in controls and compliance with the Center for Medicare and Medicaid Services (“CMS”) requirements as well as any other relevant agency and organizational policies and procedures. As our Senior Compliance Auditor, you need to be knowledgeable about the regulatory requirements that apply to the areas subject to auditing and monitoring activities as conducted under the compliance program.

The fundamentals for the job…

• Identifying and managing potential risks associated with delegation of services, such as data breaches, compliance violations, or operational disruptions.
• Manage the execution and documentation of all auditing and monitoring activities, according to the established annual work plan.
• Ensure processes are followed in accordance with policies and procedures and regulatory guidance.
• Perform analysis and trending compliance audits. Continuously evaluate specific audit/monitoring activities and determine if more formal or in-depth interventions are required.
• Prepare clear and concise reports with the evaluations of risk, root cause, and scope of impact of the internal audit findings.
• Performance Monitoring- tracking and evaluating the performance of delegated entities through regular reporting, audits, and reviews to ensure accountability and transparency.
• Develop and implement audit tools based on regulatory protocols and guidance.
• Work with areas to identify root cause and ensure any findings are corrected promptly and documented properly.
• Perform follow-up monitoring as required to assess improvement on findings and ensure effectiveness of corrective actions resulting from previous audit/monitoring activities as well as issue management process.
• Act as liaison between Clients and the Company for the coordination of external audits, facilitating a responsive and responsible audit process, including corrective actions, if applicable.
• Keep up to date with regulatory requirements and best practices.
• Create or review any policies and procedures or training, as needed.
• Establish and manage communication and escalation methods.
• Serve as liaison between Compliance and Abarca business units relating to all audits performed by client or regulatory agencies.
• Coordinate with areas for reporting requirements or audit universe submissions, including gathering reports, performing quality assurance validations and final submission to clients.
• Other Compliance, audit, or reporting requirements activities as needed.

 

What we expect of you

The bold requirements…

• Bachelor’s or Master’s degree in Health Services Administration, Public Health, Health Evaluation, Health Economics, Statistics, Science, or a related mathematics field. (In lieu of a degree, equivalent relevant work experience may be considered)
• 6+ years of experience in Medicare Part D Compliance or Audits.
• Experience in PBM Operations.
• Experience executing audits to evaluate compliance with CMS regulations and Part D requirements, including but not limited to coverage determinations, appeals, credentialing, PDE submissions, and formulary management.
• Demonstrated ability to work in collaboration with internal and external stakeholders.
• Strong problem-solving and negotiation skills within a regulatory context.
• Excellent oral and written communication skills.
• We are proud to offer a flexible hybrid work model, which will require certain on-site workdays (Puerto Rico location only).

Nice to haves…

• Certified in Healthcare Compliance (CHC), and/or Certified Fraud Examiner (CFE), and/or Certified Internal Auditor (CIA).

Physical requirements…

• Must be able to access and navigate each department at the organization’s facilities.
• Sedentary work that primarily involves sitting/standing.

At Abarca we value and celebrate diversity. Diversity, equity, inclusion, and belonging are guiding principles of Abarca and ensure Abarca’s workforce reflects the communities it serves.  We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.

Abarca Health LLC is an equal employment opportunity employer and participates in E-Verify. Abarca Health LLC does not sponsor employment visas at this time.

The above description is not intended to limit the scope of the job or to exclude other duties not mentioned. It is not a final set of specifications for the position. It’s simply meant to give readers an idea of what the role entails.

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