Responsible for providing enterprise-wide reporting and oversight of federal and state regulatory implementation, compliance and exam activities. Communicates state and federal laws and regulations throughout the company. Supports and provides expertise to corporate-wide projects and monitoring the development of implementation plans, gap analysis, milestone dates, and other significant aspects of corporate-wide projects. Provides guidance to and works collaboratively with compliance areas, Legal, IT, Planning and Project Execution Units, and the Enterprise Portfolio Management Office to identify and implement improvements in the company's regulatory process. Leads and manages enterprise-wide efforts to improve responsiveness to and consistency of company responses to market conduct exams; and provides enterprise-wide reporting on exam status, penalties and trends. Obtains and maintains an awareness of industry regulatory trends, organizational developments, and company strategies that could impact the success of regulatory projects. Subject matter expert of Medicaid contract, rules, regulations governing business operations and State Agency expectations with responsibility for educating and advising the business. Primary liaison with the State Agency Contract Manager, facilitating communications between the parties and ensuring an organizational focus on meeting contractual obligations and State Agency deliverables. Coordinates regulatory reporting deliverables, ensuring timeliness, accuracy and completeness of report and data submissions to the State Agency. Responsible for the internal prep and management of monthly on-site State Agency audit reviews.

Responsible for coordinating compliance activities and initiatives across the PBM and the enterprise by maintaining department approved regulatory and legislative compliance plan and implementing effective internal controls. Primary duties include, but are not limited to: Identifies, monitors, revises and tracks business unit processes and implementing procedures to ensure compliance with all related measures. Identifies potential risks associated with PBM activities and ensures procedures are in place to minimize risks. Partners with business units to ensure compliance with all statutory and regulatory requirements. Participates as compliance subject matter expert on all mandated projects; achieves business operational compliance initiatives. Conducts, directs, leads and facilitates all activities related to Internal and External (Regulatory and Client) audits and responds to findings. Performs high level regulatory research, develops strategic plans and pro-actively anticipates business needs and requirements. Develops and implements training and communication plans; manages and leads scheduled and ad-hoc compliance projects; provides and delivers compliance consultation services to the business unit.

Manages the Pharmacy regulatory and compliance (R&C) services program for multiple Medicaid markets. Serves as the liaison and pharmacy subject matter expert with both Corporate and health plan Regulatory and Compliance Pharmacy regulatory/contractual requirements. Responsible for managing the day-to-day activities of assigned pharmacy R&C team members. Ensures the accurate and timely submission of Pharmacy R&C reports for all markets.Lead activities in support of Amerigroup’s understanding of and compliance with federal and state regulatory requirements, contractual obligations that the Amerigroup Pharmacy department is subject to as a state contractor. Operates as the Pharmacy internal subject matter expert in the education of health plan and corporate staff on market and product specific pharmacy regulatory and contractual requirements. Provide key stakeholders with information and resource tools to promote informed and strategic decision making and planning. Ensure timely review, assessment and completion of Compliance Alerts, State and Federal agency alerts and corporate regulatory or compliance communications. Develop and maintain ongoing regulatory and compliance oversight of Pharmacy reporting requirements; Research and document pharmacy requirements, and develop and/or maintain customer-focused resource tools. Leads/co-leads the review, preparation and submission of pharmacy related audits and readiness review materials required for implementations or scheduled audits. Ensures the review, and communication of new or revised state and federal regulations, legislation, public program contracts and other state or federal issued guidance material related to pharmacy.

Provided leadership and oversight related to the operations of formulary, Preferred Drug List (PDL) and drug file communications as well as pharmacy benefit designs and modifications. Developed and implemented policies, procedures, and processes that ensured the timeliness and accuracy of implementing formulary changes and drug file processes. Responsible for developing and leading tactical improvements in the quality and efficiency of these processes and leads cross functional teams to ensure accuracy and timeliness of deliverables related to member safe drug use and specific pharmacy benefit savings initiatives. Responsible for the management and oversight of all related projects and processes, involving both internal staff and vendor resources.Responsible for leading and managing the processes for member, provider and internal communications, formulary and Prior Authorization (PA) system implementations and maintenance; developed and documented standard processes and procedures to ensure comprehensiveness and replicability in the areas of regulatory compliance, communications, formulary postings, prior authorization systems and pharmacy claims systems. Managed a team of claims resolution analysts / claims research specialists in a systematic and ongoing pharmacy claims surveillance program to ensure claims are processing as intended; ensured coding issues are identified and resolved and opportunities to minimize risks of fraud, waste, abuse and misuse are appropriately addressed. Participated in departmental vendor oversight committee activities.