Drug Claims Processing SME

Our benefits include a share purchase plan, a profit-sharing program, wellness credits, and flexible schedules that promote excellent work-life balance.

Candidates within a 50 miles radius of a CGI Federal office will have to report to the office 2 days per week

Your future duties and responsibilities
• Devise and implement prescription drug pricing and payer coverage contracting strategies to meet the legislative drug price reduction mandates of the Inflation Reduction Act (IRA) of 2022.
• Collaborate with experts and business leaders, leading both quantitative and qualitative pricing/contracting analyses to support the drug claims/rebate ecosystem.
• Understand the U.S. healthcare market, Medicare Part B and Part D processes, data flows, and pharmacy reimbursement processes.
• Collect, analyze, and validate Part D and Part B claims for negotiated drugs and identify reimbursements / rebates related to negotiated Maximum Fair Price (MFP).
• Bring thought leadership to implementing improvements to better manage/track claims and reimbursements across entire ecosystem.
• Regularly engage with senior leadership to translate strategy into action.
• Communicate results in a timely manner through disciplined management and performance measurement.

Required qualifications to be successful in this role
• Bachelor's degree or advanced degree from an accredited institution or an equivalent number of credits in pharmacy, business, economics, budget, management, computer science.
• 7-10 years of experience with work directly related to processing claims from Part D dispensers like Pharmacies, Health plans, PBMs and Part B dispensers such as physicians, hospitals and other entities.
• Knowledge and experience with Medicare and the pharmaceutical/drug supply chain including pharmacy switches.
• In-depth understanding of the current relationships and interactions between drug manufacturers, wholesalers, plan administrators/plans, PBMs, pharmacies/other dispensing entities, and beneficiaries.
• Experience with receiving and processing daily claim files from Medicare payers and/or other entities (such as 340B third-party administrators (TPAs)) for MFP-eligible beneficiaries for paid MFP claims and return a response file.
• Experience with validating clean claims from dispensers for selected drugs with an MFP (such as confirming the NDC/HCPCS for the selected drug, confirming the dispenser, checking for duplicates, checking for 340B status, checking for claims adjustments, and other validation exercises).
• Knowledge and experience calculating manufacturer reimbursement amounts for shortfall between purchase price and MFP.
• Leverage knowledge of Medicare Part B and D claims processing and assist in designing an IT solution for tracking financial transactions across drug manufacturers, wholesalers, plan administrators/plans, PBMs, pharmacies/other dispensing entities.
• Proven ability to combine vision, creativity, and innovation to solve problems with strong business acumen, well-developed management, and leadership qualities.
• Ability to interpret policy and propose business solutions/initiatives related to the Inflation Reduction Act of 2022 and interpret the IRA requirements for implementation.
• Ability to analyze, develop and perform quality assurance and validation exercises related to Part B and Part D IRA MFP drug claim data and adjustment activities to encompass drug manufacturer, wholesaler, PBM, dispenser, TPA, and health plans ecosystem.
• Experience using a managed care claims processing application (e.g., Modeln) is a plus.
• PMP Certification is a plus.
• Excellent communication and collaboration skills to work with various stakeholders, teams, sponsors, members, vendors, senior management, providers, and pharmacists.
• Strong analytical problem-solving skills and excellent interpersonal skills.
• Ability to effectively communicate both verbally and in writing with customers, team members, and management.
• Proactive and self-starting, with the ability to work independently and in a team environment.
• Exceptional attention to detail.

CGI is required by law in some jurisdictions to include a reasonable estimate of the compensation range for this role. The determination of this range includes various factors not limited to: skill set level; experience and training; and licensure and certifications. CGI typically does not hire individuals at or near the top of the range for their role. Compensation decisions are dependent on the facts and circumstances of each case. A reasonable estimate of the current range is $108,600 - $190,100.

CGI Federal anticipates accepting applications for this position through 5/31/2024.

#CGIFederalJob
#HSS
#DICE
#LI-RJ1

Together, as owners, let's turn meaningful insights into action.

Life at CGI is rooted in ownership, teamwork, respect and belonging. Here, you'll reach your full potential because...

You are invited to be an owner from day 1 as we work together to bring our Dream to life. That's why we call ourselves CGI Partners rather than employees. We benefit from our collective success and actively shape our company's strategy and direction.

Your work creates value. You'll develop innovative solutions and build relationships with teammates and clients while accessing global capabilities to scale your ideas, embrace new opportunities, and benefit from expansive industry and technology expertise.

You'll shape your career by joining a company built to grow and last. You'll be supported by leaders who care about your health and well-being and provide you with opportunities to deepen your skills and broaden your horizons.

Come join our team-one of the largest IT and business consulting services firms in the world.

Qualified applicants will receive consideration for employment without regard to their race, ethnicity, ancestry, color, sex, religion, creed, age, national origin, citizenship status, disability, pregnancy, medical condition, military and veteran status, marital status, sexual orientation or perceived sexual orientation, gender, gender identity, and gender expression, familial status, political affiliation, genetic information, height, weight, or any other legally protected status or characteristics.

CGI provides reasonable accommodations to qualified individuals with disabilities. If you need an accommodation to apply for a job in the U.S., please email the CGI U.S. Employment Compliance mailbox at US_Employment_Compliance@cgi.com. You will need to reference the Position ID of the position in which you are interested. Your message will be routed to the appropriate recruiter who will assist you. Please note, this email address is only to be used for those individuals who need an accommodation to apply for a job. Emails for any other reason or those that do not include a Position ID will not be returned.

We make it easy to translate military experience and skills! Click here to be directed to our site that is dedicated to veterans and transitioning service members.

All CGI offers of employment in the U.S. are contingent upon the ability to successfully complete a background investigation. Background investigation components can vary dependent upon specific assignment and/or level of US government security clearance held. CGI will consider for employment qualified applicants with arrests and conviction records in accordance with all local regulations and ordinances.

CGI will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with CGI's legal duty to furnish information.