Credentialing Specialist I, Amazon Pharmacy

Risk Manager I

Amazon Pharmacy is committed to building the future of pharmacy by offering technology solutions that drive and enable us to be the world's most customer centric pharmacy option. The Payer Biz Dev team is seeking a Risk Manager I to develop and execute foundational submission, reporting, risk analysis, and management for provider credentialing. This position will be heavily involved in cross-functional activity and external PBM & State Medicaid communications. This individual will build and scale operational processes for pharmacy credentialing and launches while ensuring alignment with 3P risks and regulatory requirements. Payers represent 88%+ of US prescription spend and a clean and organized input filing is a requisite for AP's success. This role is critical to AP as it is the primary mechanism to maintain payer credentials and reduce unintended network impacts. The ideal candidate will have a broad understanding of the healthcare sector with strong organizational skills, an analytical toolset to deep dive, create efficiencies, manage risk tolerances, and optimize existing policies.

Key responsibilities :

• Streamline Payer & Medicaid credentialing and cross-team processes by introducing improved controls, enhancing operational efficiency, and successfully delivering projects
• Manage upstream dependencies (Payer Relations, Compliance, Ops Compliance, Tax, Legal, Global Risk, Ops & Biz Tech), and downstream dependencies (FinOps, Reimbursement, Audit, Accounting, B2B, and Quality) to ensure timely & accurate collection, validation, and ultimately dissemination of information to external customers.
• Develop tracking mechanisms and implement risk management policies by partnering with Legal & Compliance stakeholder groups to proactively minimize identified risks and reactively address operational gaps.
• Improve existing processes iteratively and introduce new initiatives to help drive down risk while meeting compliance and policy requirements as it pertains to financial penalties, customer accessibility, insurance coverage of new FCs, electronic remittance, and payments.
• Handle day-to-day stakeholder inquiries, route payer correspondence to the relevant owners, and collaborate with partner teams to drive projects, while creating long-term scalable solutions that improve stakeholder accountability.
• Evaluate and address potential risks to the company with upstream and downstream stakeholder groups, including network termination, financial penalties, operational blockers, and payer compliance risks.
• Ensure compliance with relevant laws and regulations through collaboration with cross-functional teams.
• Work backwards with key stakeholders in developing proactive mechanisms in order to evaluate operational gaps and scope out new business initiatives, considering the potential risks and rewards.
• Provide expert guidance and support to team members on risk management escalation and issues.
• Stay informed of industry developments, changing regulations, and emerging risks in the pharmacy sector.