Pharmacy Commercial Compliance Specialist

Pharmacy Commercial Compliance Specialist

New York, New York


Ensure timely and compliant pharmacy operations for Commercial and Exchanges lines of business for both EmblemHealth and ConnectiCare.  Review Commercial regulatory directives released by Commercial compliance and determine next steps for the organization to maintain or achieve compliance.  Define business requirements to ensure compliance with Commercial compliance requirements.  Monitor operational processes for compliance and provide routine updates on process execution and improvement initiatives.  Create systemic solutions to challenges identified by Commercial compliance or internal oversight.  Develop and deliver training as required to reinforce compliance


  • Collaborate with Commercial Compliance department to manage regulatory risk sustainability.
  • Oversee the Commercial Compliance Regulatory Directives which include research, interpret, and communicate with appropriate parties to facilitate understanding of the guidance, which often represent regulatory and operational changes; define actions to be taken; provide recommendations and lead the implementation of required actions, disclosures and communication; follow through to ensure resolution.
  • Define dashboard metrics required; collaborate with reporting team to deliver; measure regularly; assess results and build the strategy for improvement, then execute against that strategy.
  • Act as the primary participant in the Mandatory Work Group Implementation meetings. Ensure all directives are implemented as needed through cross functional collaboration within and across pharmacy and other functional areas
  • Lead on all Pharmacy Commercial compliance policies including those governing oversight, investigation, retro review processes, investigations and remediation
  • Lead Pharmacy Commercial Compliance team in performing (and in untimely evaluating and redesigning where appropriate) all Compliance functions including monitoring, internal and external audits, and reports - specific to Emblem's and ConnectiCare's lines of business.
  • Develop a commercial compliance pharmacy dashboard, measure weekly/monthly sharing results across pharmacy and leadership.
  • Participate in 1/1 implementation ensuring all Commercial and Exchanges requirements are tested and successfully implemented.
  • Collaborate with the Data & Analytics Team to structure and define internal reporting and monitoring processes, enabling Commercial compliance to fulfill their oversight duties.
  • Partner with Compliance on issues and changes when appropriate.
  • Prepare supporting statements for Commercial compliance disclosure.
  • Provide technical and subject matter expertise support to other areas as needed
  • Perform independent research to maintain industry level knowledge in order to proactively address current and forthcoming changes in the healthcare environment.
  • Other duties as assigned.


  • Bachelor's degree required, advanced degree preferred.
  • 3 - 5 years of relevant work experience required
  • 2 - 3 years specific healthcare related experience, preferably in a pharmacy organization required
  • Working knowledge of health insurance regulations, processes, and structure required
  • Knowledge of Federal and State (NY) pharmacy regulations required
  • Strong communication skills (verbal, written, presentation) required
  • Excellent critical thinking and problem-solving skills required
  • Ability to collaborate cross functionally and to challenge the status quo required
  • Proven ability to analyze data, identify trends, calculate impact, and synthesize that data into actionable information required
  • Ability to lead and develop others required

Additional Information

  • Requisition ID: 21129

Salary Range
$60,000.00 - 99,000.00
per Year
Salary range estimated by
New York, NY 10001, US
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