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Compliance Lead - Government Pharmacy Benefit Management

Remote

RxSense is a leading healthcare technology company delivering innovative solutions for pharmacy benefits and prescription savings. Our enterprise platform brings transparency, flexibility, and efficiency to pharmacy benefit management, helping clients streamline operations and enabling consumers to save on prescriptions. By integrating intelligence across the pharmacy ecosystem, RxSense makes cost-effective healthcare more accessible. Whether for PBMs, pharmacies, or individuals, our solutions help modernize operations, reduce costs, and improve outcomes. 

RxSense also owns and operates SingleCare, a free prescription savings service that offers consumers access to consistently low prices on prescription drugs. Through its partnerships with the country’s largest pharmacies and grocers, including CVS, Walgreens, Walmart, Kroger and Albertsons, SingleCare improves access and adherence to affordable medications and has helped millions of Americans save over $11 billion on their medications. 

RxSense is a great place to work! Our company has earned several prestigious awards, including Fast Company’s Most Innovative Companies, Forbes’ Top Startup Employers, Modern Healthcare's Best Places to Work in Healthcare, and Inc’s Best in Business and Best Workplaces.

Position Overview:

The Compliance Lead will establish and oversee the comprehensive compliance program infrastructure for our pharmacy benefit management operations, with specialized focus on government healthcare programs including Medicare Part D, Medicaid, and ACA marketplace plans. This high-visibility position is critical for establishing program credibility, ensuring operational integrity, and maintaining adherence to complex federal and state regulatory requirements.

Key Responsibilities:

Compliance Program Development

  • Establish and maintain comprehensive compliance program infrastructure meeting CMS requirements
  • Develop and implement compliance policies, procedures, and internal controls for all PBM operations
  • Create written compliance plans incorporating the seven elements of an effective compliance program
  • Design and oversee compliance training programs for all staff levels
  • Establish compliance committee structure and governance framework

Regulatory Monitoring & Oversight

  • Monitor evolving federal and state regulations affecting PBM operations
  • Interpret CMS guidance, HPMS Memos, DHHS-OIG advisories, and state regulatory updates
  • Develop compliance monitoring protocols and oversight mechanisms
  • Create regulatory change management processes to assess operational impact
  • Maintain regulatory compliance calendar for all reporting requirements

Audit & Risk Management

  • Develop comprehensive audit frameworks for CMS, state Medicaid, and internal compliance and readiness reviews
  • Prepare organization for CMS program audits across all audit domains (ODAG, CDAG, formulary administration)
  • Create mock audit programs and readiness assessments
  • Establish corrective action plan (CAP) development and tracking systems
  • Implement fraud, waste, and abuse (FWA) detection and prevention programs

Government Program Compliance

  • Ensure Medicare Part D compliance including:
    • Coverage determinations and appeals processes
    • Formulary management and P&T committee oversight
    • Beneficiary communications and marketing materials
    • Part D reporting requirements and data submissions
    • Medication Therapy Management (MTM) program compliance
  • Manage Medicaid compliance requirements:
    • State-specific pharmacy benefit requirements
    • Managed care organization (MCO) pharmacy services contract compliance
  • Oversee ACA marketplace compliance:
    • PBM transparency reporting requirements
    • Rebate and discount disclosure protocols
    • Price concession reporting standards

Operational Integration

  • Embed compliance controls directly into operational workflows
  • Partner with operations teams to develop compliant processes
  • Review and approve all member materials, communications, and system configurations
  • Establish prior authorization and utilization management compliance protocols
  • Ensure pharmacy network contracts meet regulatory requirements

Risk Mitigation & Enforcement

  • Conduct risk assessments across all operational areas
  • Develop risk mitigation strategies and monitoring plans
  • Manage regulatory investigations and enforcement actions
  • Oversee responses to CMS notices and audit findings
  • Coordinate with legal counsel on compliance matters

Stakeholder Management

  • Serve as primary compliance liaison with CMS and state regulators
  • Present compliance updates to board of directors and executive leadership
  • Manage relationships with external auditors and compliance consultants
  • Coordinate with health plan partners on compliance requirements
  • Represent organization at industry compliance forums and regulatory meetings

 

Required Qualifications

  • Bachelor's degree required; JD, Master's in Healthcare Administration, or related advanced degree preferred
  • 8+ years of healthcare compliance experience, with 5+ years in PBM or managed care
  • 5 + years of experience with Medicare Part D compliance programs
  • Proven track record of building compliance programs in regulated healthcare environments

Regulatory Expertise

  • Expert knowledge of Medicare Part D regulations and CMS requirements
  • Deep understanding of Medicaid pharmacy benefit regulations
  • Familiarity with ACA requirements affecting PBMs
  • Knowledge of HIPAA, fraud and abuse laws, and Anti-Kickback Statute
  • Experience with state pharmacy practice acts and PBM licensing requirements

Technical Knowledge

  • Understanding of PBM operations, claims processing, and formulary management
  • Knowledge of pharmacy network contracting and reimbursement methodologies
  • Familiarity with Part D systems and data requirements
  • Experience with compliance monitoring tools and audit software

Leadership Capabilities

  • Proven ability to build and lead compliance teams
  • Strong project management and organizational skills
  • Excellent written and verbal communication abilities
  • Ability to influence and drive compliance culture across organization
  • Experience presenting to senior leadership and regulatory bodies

Preferred Qualifications

  • Certified in Healthcare Compliance (CHC) or Certified Compliance Professional (CCP)
  • Experience with PBMs or health plan compliance
  • Background or experience with pharmacy operations or clinical pharmacy
  • Familiarity with state Medicaid managed care regulations

Key Competencies

  • Ethical leadership and integrity
  • Analytical and critical thinking
  • Risk assessment and mitigation
  • Regulatory interpretation and application
  • Strategic planning and execution
  • Stakeholder management
  • Problem-solving and decision-making
  • Attention to detail
  • Adaptability and resilience

RxSense believes that a diverse workforce is a more talented and productive workforce. As such, we are an Equal Opportunity and Affirmative Action employer. Our recruitment process is free from discriminatory hiring practices and all qualified applicants are considered for employment without regard to race, color, religion, sex, gender, sexual orientation, gender identity, ancestry, age, or national origin.  Neither will qualified applicants be discriminated against on the basis of disability or protected veteran status.  We believe in the strength of the collaboration, creativity and sense of community a diverse workforce brings. 

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