Senior Manager, Managed Care Rebate Integrity – Controls

Role Overview

• Set enterprise validation strategy and own end-to-end rebate revenue integrity across pharmacy and medical benefit claims, establishing the validation “control tower” for eligibility, pricing, formulary/coverage compliance, utilization logic, unit conversions
• ensuring the organization pays only on validated, contract-compliant utilization.
• Establish and oversee data integrity governance for rebate submissions, including lookback methodologies, product and plan eligibility controls duplicate for integrity, duplicate detection (including 340B/Medicaid overlap prevention), unit of measure normalization, quantity/day supply analytics, dispenser eligibility and exclusion enforcement.
• Lead contract operationalization and policy translation in partnership with Contracting/Legal: interpret and operationalize eligibility rules, rate structures, utilization definitions, and data submission requirements; recommend contract language enhancements to reduce ambiguity, increase leverage, and prevent leakage before it occurs.
• Maintain strong understanding of PBM/MBM formulary structures, coverage criteria, benefit design changes, and how they impact rebate qualification.
• Serve as subject matter expert on PBM/MBM formulary structures and benefits design changes for financial, contractual and GTN impact.
• Sponsor, Design & Lead payer rebate audit program (third-party).
• Set risk-based cadence and audit plan; manage auditor relationship; define scope, sampling, and data requests; oversee audits validating payer claims/submissions; drive recoveries, corrective actions, and executive reporting to protect rebate revenue.
• Drive alignment across Government Pricing, Chargebacks, and Gross-to-Net (GTN) functions, ensuring consistent treatment of rebates, accrual methodologies, reporting transparency, and downstream financial integrity.
• Lead development of analytics and automation strategy, delivering executive dashboards and KPIs including validation effectiveness, denial root causes, dispute win rates, cycle time performance, recovery value, exposure tracking, and vendor SLA adherence.
• Provide strategic accrual oversight and forecasting partnership with Finance/FP&A, incorporating validity trends, seasonality, exposure risk, and emerging utilization shifts into forecasting and true-up processes.
• Ensure audit-ready documentation and governance, maintaining defensible dispute rationales, financial traceability, and recovery tracking consistent with internal controls and external audit expectations.
• Identify systemic drivers of recurring disputes and financial leakage, leading cross-functional corrective actions, control redesign, and master data enhancements to prevent recurrence.
• Provide executive oversight of outsourced/vendor relationships (e.g., IQVIA), ensuring performance against SLAs, quality standards, control effectiveness, error remediation, and continuous improvement initiatives.
• Ensure enterprise compliance with contractual obligations, audit standards, and Gross-to-Net (GTN) policy requirements, mitigating financial, regulatory, and reputational risk.
• Lead audit engagement and regulatory support efforts related to PBM/MBM rebate programs, serving as primary point of accountability for data integrity, documentation, and compliance response.

Requirements

• Bachelor’s degree in finance, Business, Analytics, Pharmacy Administration, Accounting, or related field.
• 8+ years in pharma/biotech rebates, managed care operations, GTN, or contract/revenue integrity, with 2–4 years people leadership.
• Strong understanding of PBM & MBM rebate programs, NCPDP data formats, formulary structures, and rebate contract terms.
• Hands-on experience with rebate validation and disputes for PBM and medical benefit (e.g., J-code claims, buy-and-bill).
• Experience working with or managing external vendors (e.g., IQVIA, Model N).
• Strong analytical abilities and experience with large datasets (Excel, Power BI, Snowflake preferred).
• Excellent communication skills for cross ‑ functional and payer/vendor interactions.
• The ability to work in a complex and changing environment with minimal supervision, make independent decisions and work within a team environment.
• Ability to initiate complex analysis, manage details, and provide strategic perspective.

Benefits

• medical
• dental
• vision coverage
• life insurance
• disability
• 401K with company contribution
• wellness program