Associate General Counsel - CarelonRx
Location : This position will work a hybrid model (remote and office). The ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations.
Elevance Health supports a hybrid workplace model with PulsePoint sites used for collaboration, community, and connection.
This position will serve as an Associate General Counsel to CarelonRx, a pharmacy benefits manager (PBM) owned by Elevance Health, Inc., providing support on a variety of legal matters primarily to PBM's mail order and specialty pharmacies.
How You Will Make an Impact:
Primary duties include, but are not limited to:
- This role will serve on a team that provides substantive legal support to CarelonRx PBM's mail order and specialty pharmacies, including working with business leaders and legal department colleagues on a wide variety of strategy, commercial contracting, licensing, compliance, innovation, and regulatory matters relevant to PBMs and specialty and mail order pharmacies.
- Position requires a keen understanding of the business, legal and regulatory environment applicable to managing multi-channel pharmacy interests/risks, including but not limited to the following areas:
- Specialty pharmacy drug procurement and services contracting, including LDD & exclusive distribution networks, REMS drugs/services, data reporting and HIPAA considerations, adherence and related pharmacy services contracting.
- 340B contract pharmacy models, contracting and operational support, knowledge of HRSA and current landscape of legal and regulatory challenges to 340B pharmacy programs.
- State and federal regulations applicable to pharmacy facility and personnel licensure (e.g., Pharmacy, Pharmacist, Pharm Tech), including federal/state Controlled Substances regulations.
- Regulatory landscape applicable to drug procurement, distribution, wholesaling activities and relationships (e.g., DSCSA, wholesaler/TPL licensure).
- Specialty & mail order pharmacy enrollment/credentialing/accreditation.
- Knowledge of drug pricing models/methodologies and associated commercial and legal issues (e.g., WAC, AWP, NADAC, DIR, MAC pricing, other pricing methodologies).
- Review and regulatory counseling pertaining to advertising/marketing/promotional rules and regulations applicable to pharmacies and/or PBM-owned pharmacy assets.
- Fraud/waste/abuse and related white collar investigatory and regulatory counseling (e.g., AKS, CMP, HIPAA, Stark) on a variety of pharmacy-related issues.
- Duties will require solid business acumen balanced with a sound risk mitigation mindset used to evaluate and articulate legal and commercial risks to business clients on a variety of matters with broad organizational impact and varying levels of risk.
- Must be able to navigate a complex and evolving regulatory environment by timely delivering sound, actionable legal advice on regulatory, strategic, and operational matters impacting owned pharmacies and PBMs.
- Manages and participates in extensive research of legal principles and precedent and consults with outside counsel where required on legal strategies on particular issues.
- Other legal duties and responsibilities as identified by senior management.
Additional duties may include:
- Providing support on areas related to PBM/Pharmacy relations, including but not limited to:
- Accreditation agencies and processes (e.g., URAC, ACHC, NABP, NCQA)
- State and federal regulations applicable to Commercial/Medicare/Medicaid lines of business and pharmacy compliance.
- Any Willing Provider and other pharmacy and network regulatory limitations (e.g., anti-mail & preferred networks allowed/not allowed).
- Providing support to PBM internal committees/processes relevant to PBM/Pharmacy networks (e.g., P&T, VAC, UM, PA).
- Wide variety of PBM/Pharmacy audit/appeals issues (e.g., MAC, FWA, CMS, Medicaid).
- PSAO contracting support.
- Familiarity with infusion provider/pharmacy relationships, models and associated regulatory challenges (e.g., provider models, AICs, home infusion, RN networks/licensure).
- M&A transactions in or involving the pharmacy sector (e.g., stock, asset purchase transactions, FWA due diligence).
- Reporting to legal and business management on identified business exposure and associated risks as well as mitigation techniques being utilized.
- Providing legal support in the resolution of disputes and inquiries from customers, subcontractors, and governmental/regulatory/accreditation agencies.
- Serves as a resource for other attorneys and contract managers as well as business clients instructing and advising on technical and tactical issues.
Minimum Requirements:
- Requires a JD, current license to practice law, and a minimum of 9 years of specific industry and/or technical legal experience post licensure; or any combination of education and experience, which would provide an equivalent background.
Preferred Skills, Capabilities, and Experience:
- 5-10 years of PBM, pharmacy or related healthcare experience, consistent with the duties of the position.
- At least 5 years of specific industry and/or technical legal experience post licensure; or any combination of education and experience, which would provide an equivalent background.
- Experienced and technically strong in drafting, reviewing, and negotiating contracts and related documents impacting pharmacies including 340B, LDDs, Payor, procurement of goods and services, etc.
- Proficient at preparing/delivering concise and timely briefings to business and legal management on assigned matters, including clear and well-developed communication skills.
- Possesses industry knowledge in one or more of the following areas consistent with essential duties of the position: pharmacy regulatory/licensing, specialty pharmacy drug procurement and manufacturer services contracting, wholesaler and related drug procurement matters, 340B regulatory and operational issues, PBM/reimbursement contracting, and operational models for specialty or mail order pharmacy.
- Detail-oriented, client-focused, and able to work effectively in a matrixed environment.
- Experience managing outside counsel and working within department budget and related administrative processes.
- Ability to manage work independently while keeping legal management appropriately informed and/or as requested.
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