Biologics Payer Audit and Accreditation Specialist

This is a fully remote position, open to applicants in Texas.

📋 Description

• Assist with the intake, logging, tracking, and prompt response to PBM audit requests across Biologics locations.

• Investigate audit findings, compile supporting documentation, and prepare responses and appeals for audits.

• Evaluate audit findings and discrepancy trends categorized by payer, site, drug, and type of discrepancy.

• Manage audit trackers, dashboards, and reporting for stakeholders in Operations, Quality, Finance, and Legal.

• Aid in the interpretation and application of state pharmacy audit regulations, terms from PBM provider manuals, and constraints of contractual audits.

• Collaborate with Operations to suggest workflow and documentation modifications that mitigate audit risk and recoupment exposure.

• Contribute to the maintenance of URAC and ACHC accreditation, submission of renewal applications, and compliance with standards.

• Support gap analysis between policies, SOPs, operational practices, and accreditation benchmarks.

• Organize and upload accreditation evidence, monitor performance measure reporting, and assist in the development and submission of RFI responses.

• Facilitate survey preparedness through mock audits, staff readiness materials, documentation reviews, and follow-up on corrective actions.

• Oversee the maintenance of accreditation documentation repositories, licensure and credentialing records, and version control.

• Contribute to continuous quality improvement efforts, quality enhancement projects, CAPA tracking, and monitoring effectiveness.

• Coordinate efforts between Payer Audit, Accreditation, Quality, Operations, and Compliance stakeholders.

• Create summaries, reports, and presentation materials for leadership and governance committees.

• Ensure accurate, traceable, and audit-ready documentation is maintained.

• Assist in the development and provision of staff education and job aids pertaining to audit readiness and accreditation standards.

⛳️ Requirements

• A degree or equivalent with typically over 4 years of relevant experience.

• At least 4 years of combined experience in specialty pharmacy, pharmacy operations, PBM, or pharmacy regulatory and payer compliance.

• Minimum of 2 years in PBM audit management and/or PBM auditor roles, which includes audit responses, appeals, and recoupment defense; OR 2 years of experience in specialty pharmacy accreditation (URAC and/or ACHC), involving standards interpretation, evidence submission, and survey support.

• Familiarity with pharmacy claims adjudication, claim rejections, and their corresponding resolutions.

• Proven track record of maintaining structured documentation, ensuring traceability, and following through on corrective actions.

• Knowledge of pharmacy systems, operations, and workflow.

• Experience in specialty pharmacy is strongly preferred.

• Familiarity with state pharmacy audit statutes and PBM provider manual audit provisions is advantageous.

• Experience with accreditation management platforms like AccrediNet or document control systems such as MasterControl is a plus.

• Proficiency with pharmacy management systems and reporting/analytics tools, including Power BI and Excel, is beneficial.

• Experience in community oncology, rare disease, or limited distribution drug environments is a plus.

• Certification as a Pharmacy Technician (CPhT) is preferred.

• Ability to effectively manage expectations of both internal and external stakeholders.

• Skill in developing collaborative relationships and partnerships with internal and external parties.

• Detail-oriented with strong capabilities in documentation and organizational discipline.

• Effective communication skills with pharmacists, pharmacy staff, operations leaders, auditors, and surveyors.

• Strong problem-solving and decision-making abilities.

• Excellent interpersonal and written communication skills.

• Self-motivated and results-driven; requires minimal supervision.

• Capacity to manage multiple workstreams with competing deadlines.

• Strong analytical skills.

• Ability to thrive in a fast-paced, dynamic, and regulated business environment.

• Proficiency in Microsoft Office; tech-savvy.

• Willingness to travel approximately 15%, including trips to Biologics locations.

• Must reside in Texas, United States, as specified by the employer's posting location.

🏝️ Benefits

• Competitive compensation package.

• Opportunities for annual bonuses or long-term incentives may be available.

• Work-from-home position.

• Approximately 15% travel required.

• Equal employment opportunities provided.

• Reasonable accommodations for job search or employment applications.