Sr. Manager, Government Rebate Operations

Position Purpose:

The Sr. Manager, Medicaid Operations leads development, implementation, and management of processes, programs, and policies to ensure that CSL adheres to all compliance requirements outlined in the Medicaid Drug Rebate Program (MDRP) regulations, Tricare and Medicare programs. Responsible for managing MDRP reimbursement process (disputes, adjudications, payments), including approving rebate requests with annual payments totaling over $120M. Proactively mentors and guides analysts towards completion of government reporting requirements and analyses. Leads the dispute resolution process with the States and their TPPs, including regular business reviews and follow-up of open issues and documented accordingly. In addition, will lead generation of analytics and insights into underlying drivers of rebate trends and provide accrual and audit support.

Main Responsibilities and Accountabilities

1. Accountable for the analysis, review and processing of Medicaid, Tricare, and Medicare claims and rebates. Approves payment of rebate claims within the system. For large disputes or adjustments, critically review analysis of utilization and reimbursements to confirm validity and reasonableness of claim/dispute. Lead team in resolving prior quarter adjustments and disputes that might arise at the state level, including collaboration with State TPPs and tracking progress toward resolution. Monitors and accounts for averted revenue leakage from dispute activities.

2. Responsible for the modeling, review and implementation of State Medicaid Supplemental or other contracts through interaction with Legal, Pricing and Government Reporting, State Government Affairs, Contract Strategy and others as necessary, to ensure contracts are prepared accurately and in a timely manner. As part of overall US SPC support, will ensure alignment to current Policies and Procedures and will maintain documentation of internal controls and related Job Aids to ensure audit readiness.

3. Monitor and provide recommendations related to system capabilities, including validation rules, to best analyze claims and report data on an ongoing basis. Working with IT, ensure system configuration aligns to best practice and efficiency that meets current business needs.

4. Provide analyses/dashboards on utilization and rebate trends; report any insights and recommendations to management on a regular basis. Generate insights to understand underlying drivers of rebate claims and collaborate with finance to ensure appropriate rebate accruals in gross-net projections Proactively assess state Medicaid drug management programs and generate recommendations to inform CSL’s state Medicaid commercial and pricing strategies.

5. Develop and maintain strong working relationships with Medicaid administrators and State agencies by handling and resolving all inquiries, questions, disputes and problems. Communicate with States to clarify contract terms and conditions, provide resolutions to outstanding Medicaid Claim related issues, etc.

6. Drive continuous improvement initiatives through processes and technology enhancements that improve the accuracy, speed and insights related to processing Medicaid of rebates and anticipation of future rebate payments across CSL’s growing portfolio of products.

7. Monitor and communicate changes in guidance for government programs and the Medicaid program that will impact operations. Review proposed updated to system/documentation with GP/IT teams and implement changes in policy or guidance the affected programs.

8. Responsible for maintaining and updating all Medicaid Rebate operations related documentation of internal control procedures and job aids on a regular basis to ensure they reflect up-to-date processes, compliance and audit readiness, in coordination with the Sr. Manager, Government Reporting. This includes ensuring alignment to implemented Policies & Procedures.

9. Participate in and provide support for internal audits of program administration, payment calculations, rebate processing and compliance.

10. Has responsibility for oversight and effective management of all team members (i.e. direct reports) to include but not limited to the following:

• Annual objective setting

• Mid-year and end of year reviews

• Coaching and counseling as appropriate

• Employee development

• Recruitment, selection and development of talent

• Managing, directing & measuring work on an ongoing basis. Provides timely constructive feedback to ensure quality of work meets or exceeds company standards

• Assuring work is completed in a customer focused manner

Education: Requires a Bachelor’s degree, preferably in Business, Life Sciences, or Healthcare Policy.

Experience:

• 8 – 10 years of biotech/pharmaceutical experience.
• Strong knowledge of the Medicaid Drug Rebate, Tricare and Medicare programs and processing claims.
• Supervisory or Managerial experience preferred
• Experience with utilization of pricing systems. Model N preferred.
• Demonstrated ability to function independently, critical thinking, prioritization and coordination of job responsibilities
• Must be proficient with Microsoft office software to include but not limited to Excel, Word Power point.

Competencies:

• Total work systems
• Developing direct reports and others
• Detail Oriented
• Customer Focus
• Managing through systems
• Business Acumen
• Integrity and Trust
• Process Management