Conducts Data Analysis for pharmacy benefit and contractual audits surrounding pharmacy claims.
PBM audits can include, but are not limited to pricing, plan design, rebates, eligibility, CMS Data Validation, Fraud, Waste & Abuse and performance guarantee review.
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.

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

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.

Pharmacy Benefit Auditor

Key skills