PerformRx is a Pharmacy Benefits Manager (PBM) dedicated to clinical culture, boutique service and holistic solutions. Our mission is to help customers, doctors and patients use effective medication therapy to improve health and wellness. For more than 15 years, our focus has been on providing optimal service through a clinical culture which seeks to provide members with high quality care while ensuring our partners receive favorable costs. That culture is reflected in our employees; more than 80 percent of our staff members are Pharmacists and Pharmacy Technicians, and in the services we provide.

PerformRx is headquartered in Philadelphia. Our dedication to innovation and to providing the most efficacious outcomes is the core of our clinical culture and is the heart of PerformRx. PerformRx is a subsidiary of the AmeriHealth Caritas Family of Companies.

Summary:

The Director, PerformRx Government Programs and Products is the primary contact for Medicare and Medicaid product development for PerformRx. The Director is the subject-matter expert (SME) for government programs and will ensure all products are functioning as expected.  The incumbent is the liaison amongst Account Management, Operations and the Regulatory/Compliance Teams. The Director assists teams across PerformRx with enhancing our current operations, testing, and offerings in the government program space. The Director will exercise due diligence to detect, prevent and report unlawful and/or unethical conduct, as well as fraud, waste and abuse.   

Responsibilities:

• Serves as the primary contact and the person responsible for ensuring overall compliance with Medicare and Medicaid compliance requirements relating to PBM program
• Coordinate implementation of system-wide programs, policies, and procedures to ensure system compliance with applicable federal and state laws and regulations.
• Coordinate written policies and procedures that set up standards for compliance; provide specific guidance to management, professional staff, and individual departments as appropriate
• Develop, implement, and maintain a system for confidential reporting and investigation of escalated government program concerns with an appropriate response process to incoude the creation of an environment that facilitates freedom to report concerns and/or incidents of wrongdoing without fear of retaliation; coordinate an external reporting system (toll free hot line), coordinating with PerformRx Compliance
• Assist Account Management in resolution and research of issues in a timely manner, and deliver responses to clients within Account Management 
• In coordination with internal legal consultants, maintain awareness of laws and regulations, keeping abreast of current changes that may impact healthcare systems. Utilize personal initiative, seminars, training programs, peer contact, and various industry information sources (i.e., Internet sites, newsletters, etc.)
• Work with our Claims Processor to act as a subject-matter expert (SME) in all areas of government programs implemented with our Claims Processor 
• Educate Account Management and other cross functional areas on government programs
• Coordinate with Network Operations to develop and implement systems and procedures to prevent and detect fraud, waste, and abuse in connection with PBM and pharmacy services
• Coordinate the development, implementation, and maintenance of audit controls and measurements for internal and external processes, ensuring correct processes are in place for accurate, complete, and compliant programs across the system, including subcontractors and/or First Tier, Downstream and Related entities (FDRs)/Vendors. Work cross-functionally to ensure identified non-compliance is remediated.
• Communicate to and work collaboratively with the Chief Compliance Officer, President of PerformRx, the PerformRx Board of Directors, and in-house Legal counsel. Prepare monthly and/or quarterly compliance summaries for the organizations leadership, as outlined above, as well as the Compliance Committee.

Education/Experience: 

• Requires Bachelor’s Degree in Healthcare and/or Regulatory related degree
• Master’s Degree preferred
• Minimum of five (5) years of management experience in Medicare Managed Care and/or Medicaid Managed Care in a Pharmacy Benefit Management (PBM) environment required
• Current/recent leadership and Compliance or Regulatory experience at a Pharmacy Benefit Management organization required
• Extensive healthcare software and computer experience
• Strong leadership, interpersonal, and problem solving skills
• Effective communication (listening, verbal and written) skills
• Demonstrates personal traits of a high level of integrity, team orientation, professionalism, and trustworthiness
• Places a high value on ethical standards and treating others with dignity and respect
• Clinical Pharmacy, Pharmacy Technician and/or Pharmacy Operations subject-matter expertise preferred
• Active/current National Pharmacy Technician Certification (ExCPT, NCCT or PTCB) a plus

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