Wellfleet, a Berkshire Hathaway company, delivers customer-centric accident and health insurance, with quality service and uncompromising ethics. Wellfleet works to protect people against risk throughout every stage of life – from grade school to college to the workplace.
Founded in 1993 as Consolidated Health Plans (CHP), Wellfleet, headquartered in Springfield, Mass., is one of the nation’s leading providers of health and accident insurance products to the higher education market. Join our rapidly growing and fast paced health insurance organizations in the Springfield, MA area.
This position requires in-depth working knowledge and experience with reviewing state and federal laws and regulations pertaining to medical management activities and pharmacy benefits and applying them to operations with vendors, including pharmacy benefit managers (PBMs) and utilization management vendors, and internal policies and procedures. This position also supports the implementation of compliance plans, resolution of issues, reporting, and other operational activities. Although supervision and guidance will be provided, this position generally requires autonomy and independence with the job duties and responsibilities outlined.
In this role, you will…

• Establish and monitor implementation plans to confirm or achieve compliance with new and revised regulations that pertain to medical management activities and pharmacy benefits as well as external UM vendors and PBMs with minimal supervision
• Analyze legislation and other guidance from licensing/regulatory entities with assistance from Legal/Compliance and exercise independent judgment, consulting with SMEs as necessary, to determine how each component impacts current organizational processes, UM vendor, and PBM activities to identify necessary changes
• Support development of internal guidelines, processes, policies, and another applicable documents to ensure compliance
• Maintain tracking tools to monitor compliance, implementation plans, reporting needs, and other ongoing activities
• Compile and analyze data, in coordination with external vendors, to complete required surveys and reports for submission to licensing/regulatory entities
• Assist with developing language and standards to support product filings and ensure these are captured in benefit checklists and other tools to support PBM benefit implementation
• Assist with quality program and delegation oversight of PBMs to ensure PBMs are meeting state, quality, and performance requirements
• Ensure department awareness and preparedness through effective communication, resource development, and training
• Coordinate with other departments to ensure required resources are available to stakeholders, including prospective/current members, providers, and pharmacies
• Generate detailed and thorough meeting minutes from external vendor and internal meetings for monitoring obligations
• Adhere to all company, regulatory, and accreditation standards, policies and procedures relating to member confidentiality documentation, quality, and turnaround times.
• Special projects and other duties as assigned.

We are looking for candidates with…

• Minimum of 4 years’ experience in a PBM, utilization management, managed care, or health insurance environment or an equivalent combination of experience and relevant education
• Excellent computer and MS Office proficiency and ability to navigate a variety of systems/portals
• Strong verbal/written communication skills, including the ability to articulate business needs related to complex laws and regulations
• Solid project management, interpersonal skills, and organizational agility
• Excellent task initiative and demonstrated analytical, problem solving and critical thinking skills
• Multi-tasking, priority setting, and detail-oriented skills applied in a fast-paced environment

Why Wellfleet?
Here at Wellfleet, we foster a culture of growth that enables engaged and high-performing professionals to be empowered to deliver our mission and vision.
Our employees are a team devoted to providing customer service that exceeds expectations of our members and clients. Successful team members continually look for ways to improve product delivery and value.
Wellfleet offers a competitive compensation package and comprehensive benefits package including life, health and dental, vision, 401K retirement plan, short- and long-term disability coverage, flexible/dependent care spending account, tuition reimbursement, and business casual dress.
Are you interested in exploring a career at Wellfleet? Explore our open positions.
General:
Wellfleet is part of the MedPro Group family. As such, all Wellfleet team members are employees of MedPro Group Inc. We are an Equal Opportunity Employer. The ideal candidate in this role will be located in the Eastern or Central time zone. #LI-Remote

Job Type: Full-time

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