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Role Description

This role supports clients by leveraging our proprietary software and PBM claims data to analyze claims data, identify findings, and develop/present findings to the clients to ensure PBMs are processing pharmacy claims in alignment with the clients’ contract.

The Senior Pharmacy Benefit Audit Specialist will develop and grow business relationships vital to the success of each audit project, which includes implementing, executing, and finalizing with strict deadlines. They will also manage project development from beginning to end which can include a variety of different types of PBM audits depending on the client audit requirements. They will additionally begin to mentor team members and begin testing new resource enhancements.

• Conducts Data Analysis for pharmacy benefit and contractual audits surrounding pharmacy claims.
• Includes gathering, implementing, executing, and finalizing audit rules and requirements from clients and PBMs into proprietary systems.
• Assists with review of PBM contract(s) and contribute suggestions for improvement, based on knowledge of industry.
• Leverages the company’s reporting systems to conceptualize, design, and distribute both operational and analytical reports focused on pharmacy utilization and cost.
• Assists with developing, documenting, and evaluating the business requirements associated with data flows to and from the PBM and other vendors.
• Identifying issues and resolutions, and consulting management on potential solutions to facilitate critical decisions.
• Generate audit reports and consult with client on the findings.
• Works effectively on multiple client assignments or projects simultaneously.
• Plan, schedule, and track project timelines, milestones, and deliverables.
• This position will include job duties that require risk designations for access to Electronic Protected Health Information (PHI) in the course of their job responsibilities.
• Other duties may be assigned.

Qualifications

• Pharmacy Technician Certification (CPhT) and/or pharmacy work experience
• Associate degree or higher (preferred)
• Direct PBM claims auditing experience within a PBM and/or Health Plan (preferred)
• Minimum of 3 to 5 years’ work experience in healthcare, health insurance fields pharmacy benefit management, with a focus on pharmacy claims processing and pharmacy benefits related activities
• Ability to build and maintain strong, collaborative working relationships with multiple business units across the company
• Strong communication skills (written and verbal)
• Ability to maintain a high level of confidentiality
• Proficient with MS Office Suite

Requirements

• Pay Range: $90,000 - $105,000 Annual

Benefits

• Health Benefits: Medical/Rx, Dental, Vision, Life Insurance, Disability Insurance
• Financial Benefits: ESPP; 401k; Student Loan Assistance; Tuition Reimbursement
• Mental Health & Wellness: Free Mental Health & Enhanced Advocacy Services
• Beyond Benefits: Paid Time Off, Holidays, Preferred Partner Discounts and more.

Company Description

As an Equal Opportunity Employer, we are committed to fostering an inclusive environment comprised of people from all backgrounds, with a variety of experiences and perspectives, guided by our Diversity, Inclusion & Belonging (DIB) motto, “The Power to Be Yourself”.