CLINICAL COMPLIANCE SPECIALIST
Make your next big career move by applying as KMC Solutions' next CLINICAL COMPLIANCE SPECIALIST
Summary: The Clinical Compliance Specialist is responsible for providing clinical support to the Provider Audit Team and assist in improving the identification and reporting of aberrant and potentially fraudulent claims, pharmacies, members, and prescribers. Works within the Provider Audit team to achieve overall departmental and company financial goals.
On top of your salary, here are the exciting benefits you can look forward to:
- Premium Benefits - The employee shall be entitled to Holiday Premium, Overtime Pay, and Night Differential.
- Leave Credits - Upon hire you shall start earning up to ten (10) leave credits with an accrual rate of 0.83 leaves per month. On your 1st Anniversary and succeeding anniversaries, you shall earn twenty (20) leave credits with a total accrual rate of 1.67 leaves per month.
- Carryover of Unused Leaves - Unused leave credits from the current year may be carried over and may be utilized by the employee until the 30th of June of the following year. Unused leave credits after the 30th of June shall be forfeited.
- Quarterly Bonus - The EMPLOYER has the sole option to grant a quarterly bonus to eligible employees based on performance evaluation and company profit goals. The employee shall meet 100 % of the required evaluation and profit goals as set forth by the employer which may vary depending on changing business needs and in no event shall exceed four (4 %) percent of the employee’s gross quarterly salary
- HMO Principal - The employee shall be entitled to a Php150,000 maximum benefit limit of HMO coverage per illness per year upon hire.
- HMO Dependent - Php150,000 per illness per year for two (2) dependents upon hire of the employee. HMO coverage for free dependents is the standard/regular coverage unless stated otherwise.
- 13th Month Pay - With a minimum rendered work of at least one (1) month during the calendar year, you shall be entitled to 13th Month Pay equivalent to 1/12 of your monthly gross salary multiplied by the number of months worked or earned within a given calendar year to be released on or before Dec 24 of every calendar year, subject to the computation as provided by the Labor Code and other pertinent issuances of the Department of Labor and Employment.
- Group Life Insurance - Employees hired between 18 to 64/65 years old and employed under probationary or regular status shall be covered by the Group Life Insurance (GLI) under the company’s service provider. The service provider shall pay to legitimately declared beneficiary/ies, with filial affinity, the corresponding amount indicated in the Schedule of Benefits (SOB). In the absence of declared beneficiaries, the hierarchy of next-of-kin or surviving class of beneficiaries shall apply. MANAGER (18 to 65 Y/O) shall be covered with the amount of insurance for LIFE, 1,000,000. ABL, 30,000. ADDB, 1,000,000. UMA, 1,000,000. TPDL, 1,000,000 and LCB, 500,000. Exclusions from claiming this benefit are as follows: (1) Suicide within the first 12 month of coverage and (2) When employee enters the military service within the course of his/her employment and (3) other exclusions and exemptions as defined under the general guidelines of the GLI policy. Kindly refer to the exclusion sections. All legitimate claims shall be subject to the general guidelines and required documentations set by the service provider. Failure to comply may result in the forfeiture of any claims.
The main responsibilities of a CLINICAL COMPLIANCE SPECIALIST include:
Essential Duties and Responsibilities include the following. Other duties may be assigned.
• Prepares and completes retrospective desktop, and targeted audits, including obtaining claim data
for analysis, reviewing dispensing activities for billing errors, reviewing federal/state/local pharmacy laws, documenting audit results, notifying pharmacies, and preparing audit plans, and schedules as appropriate.
• Responsible for providing clinical support services to department and to client plan(s) contracting for
audit services. Support services will include, but not limited to, clinical review, data query recommendations, and audited claims review; particularly those reviews requiring clinical expertise (e.g., compound and specialty claims).
• Review audit guidelines and algorithms for clinical appropriateness and operational efficiency. Assist in the revision and creation of new or existing audit guidelines and algorithms as indicated.
• Provide drug information support. Research and provide clinical documentation to support reporting and algorithm needs as indicated. May include recommendations for audit criteria based on known or suspected drug schemes including diversion, doctor, and pharmacy shopping, etc.
• Coordinate and assist in the preparation of utilization and audit reporting for client plans based on fraud, waste and abuse reports and data queries. Ensure timely preparation and review of claims data and client reports, when required.
• Coordinate and assist with projects to identify, analyze, and report on new fraud schemes that may impact MedImpact clients.
Client Responsibilities
This is primarily an internal client facing position but may require external client communication from time to time. The incumbent is required to have excellent customer service skills and interpersonal communication skills (listening/verbal/written).
To apply, you must be an expert on the following requirements:
Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education and/or Experience
Pharmacy degree (Pharm. D.) or equivalent; and 2+ years related retail experience and/or training; or equivalent combination of education and experience.
Computer Skills
Intermediate to advanced skill set in MS Office (Word, Excel, PowerPoint, Project, and Outlook) required. Familiarity with relational database systems and SQL software front ends such as Cognos highly desirable. Intermediate to advanced skill set in MedAccess, and SalesForce preferred. Strong aptitude to learn and adapt to new programs.
Certificates, Licenses, Registrations
Current, unrestricted Registered Pharmacist license in the State of California or a state of the United States.
Other Skills and Abilities
Excellent working knowledge of all types of pharmacy services with an emphasis on the managed health care environment. Expertise in clinical application of pharmacy practice.
Reasoning Ability
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
Mathematical Skills
Ability to work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
Language Skills
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the public.
It will also be favorable if you are knowledgeable in:
Competencies
To perform the job successfully, an individual should demonstrate the following competencies:
- Analytical - Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data; Designs workflows and procedures.
- Cost Consciousness - Works within approved budget; Develops and implements cost saving measures; Contributes to profits and revenue; Conserves organizational resources.
- Interpersonal Skills - Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others' ideas and tries new things.
- Oral Communication - Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; Responds well to questions; Demonstrates group presentation skills; Participates in meetings.
- Problem Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics.
- Quality - Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance; Monitors own work to ensure quality.
- Quantity - Meets productivity standards; Completes work in timely manner; Strives to increase productivity; Works quickly.
- Teamwork - Balances team and individual responsibilities; Exhibits objectivity and openness to others' views; Gives and welcomes feedback; Contributes to building a positive team spirit; Puts success of team above own interests; Able to build morale and group commitments to goals and objectives; Supports everyone's efforts to succeed.
- Technical Skills - Assesses own strengths and weaknesses; Pursues training and development opportunities; Strives to continuously build knowledge and skills; Shares expertise with others.
- Written Communication - Writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Presents numerical data effectively; Able to read and interpret written information.
- Self-initiative - Ability to act proactively and take action without being told, recognizing what needs to be done and having a level of confidence to finish tasks and assignments in a timely manner.
The successful candidate must submit the following pre-employment requirements
- Scanned copy of valid NBI Clearance
- Accomplished Medical or PEME Slip (covered by KMC)
- 2x2 & Half body picture with white background
- Proof of government numbers (TIN, SSS, Pag-ibig, & Philhealth)
- Photocopy of 2 valid IDs – front & back (government-issued)
- Clear copy of your Birth Certificate (PSA or NSO)
- Accomplished HR Forms & Promissory Note (will be provided by KMC’s Onboarding Team
Click here to view the complete list of KMC’s pre-employment requirements.
KMC Careers
If you're a rockstar at what you do and looking to be a part of our amazing story, we want to hear from you!
We offer attractive salaries and benefits plus you get to work in some of the Philippines' best flexible workspaces. Our employees also get to enjoy exclusive discounts, rewards and freebies, and invites to our monthly events. We are always recruiting for roles in IT & Development, Marketing, Business Administration, HR & Recruitment and Legal & Finance Roles.
KMC provides quality employment opportunities for job-seekers looking for a career that is both challenging and fulfilling. We are also committed to providing equal opportunities at every selection stage. We do not discriminate due to age, gender, sexual orientation, ethnicity, nationality, and religion.
Work with Us. Grow with Us.
KMC Solutions offers a variety of career opportunities in Metro Manila, Cebu and Clark & Iloilo. We are always looking for talented and enthusiastic individuals who are ready to make their next big career move.
Our Culture
At KMC, we foster an inclusive and positive workplace for all. We push our members to succeed in everything they do through our collaborative work environment. We encourage our community to work hard and reach their full potential while delivering results that matter for our members and you as professionals.
We host amazing and quality events and implement people-centric policies to work flexibly. We ensure that everyone in our expansive network is engaged, from our internal employees and those who work on behalf our offshore partners.
Life within KMC: Work Hard Party Harder
At KMC, we work hard and we are committed to putting our best foot forward in everything we do. Everyone is encouraged to be an individual while also working for the collective good of the KMC Community. We believe mistakes are opportunities and that you should not present a solution without a problem.
We also know when hard work deserves to be recognized so we reward our employees with monthly parties, free trips and much much more!
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