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RxSense

👥 251-500💰 Private about 5 years agoInformation ServicesInformation TechnologyCloud ManagementHealth CareSoftware💼 Private Company
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RxSense is a high-growth healthtech company revolutionizing pharmacy benefits administration. We provide sophisticated, cloud-based enterprise solutions that empower pharmacy benefit managers, health plans, and other industry entrants with flexible, efficient, and transparent claims processing and advanced analytics. Our platform helps clients control costs, improve operational performance, and ultimately deliver better healthcare to patients nationwide. Our tech stack leverages modern technologies to drive our mission. We utilize iPhone/Mobile Compatibility, Viewport Meta, SPF, SSL by Default, Google Font API, and Content Delivery Network, and other technologies, enabling us to deliver seamless, user-friendly experiences. We are committed to innovation and offer a collaborative work environment, fostering a culture of creativity and problem-solving. Our engineering teams work to solve complex problems in the healthcare space. We are a fully remote company. Our team is committed to our company mission and values. Founded in 2015, RxSense has quickly become a leader in the health technology sector. We've been recognized as one of 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. We're a company of 251-500 employees with a robust funding history, including a recent private equity round, and we're constantly seeking talented individuals to join our growing team and contribute to our mission.

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Jobs at this company:

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🔥 Compliance Lead - Government Pharmacy Benefit Management
Posted 7 days ago

🔍 Healthcare Technology

  • 8+ years of healthcare compliance experience, with 5+ years in PBM or managed care
  • 5 + years of experience with Medicare Part D compliance programs
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
Posted 7 days ago
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