Pharmacy Benefit Management Examiner

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

📋 Description

• Oversee PBM audit assessments across various states and PBM entities in line with state regulations.

• Evaluate pharmacy audits carried out by PBMs, including pharmacy reimbursements, health plan and pharmacy contracts, manufacturer revenue like Rx rebates, MAC appeals, claims processing, and network adequacy.

• Execute PBM examination tasks within the required state software platform.

• Analyze state rules and regulations related to PBM enforcement requirements and examinations.

• Manage multiple examiners and the workflow processes associated with each PBM examination.

• Delegate tasks to PBM staff while ensuring compliance with examination workplan requirements and expectations.

• Guarantee that audit deliverables are finalized promptly and accurately.

• Support the management of relationships with client and examinee company points-of-contact.

• Collaborate and strategize with PBM leadership to drive program success.

• Track and summarize new state and federal compliance legislation, regulations, sub-regulatory guidance, and case law affecting PBM operations.

• Assist leadership in PBM practice development activities, strategic discussions, tasks, and partnerships.

• Adapt to a dynamic and fast-paced work environment.

⛳️ Requirements

• Previous experience in PBM auditing or operations is essential.

• Professionals from the PBM industry are encouraged to apply (e.g., CPBS, CPhT, etc.).

• Experience conducting examinations per the NAIC Market Regulation Handbook, or having a background as an attorney, accountant, auditor, examiner, or analyst within a state insurance department, public accounting firm, PBM, insurance company, or state/Federal agency is preferred.

• Capability to achieve the Certified Insurance Examiner (CIE), Market Conduct Management (MCM), and/or other relevant designations applicable to the PBM industry, including fulfilling continuing education requirements.

• Proven experience in leading teams.

• Outstanding skills in legal research, writing, and verbal communication.

• Strong interpersonal, presentation, analytical, legal, and audit/examination capabilities.

• Excellent organizational skills with the ability to prioritize multiple tasks that have competing priorities, projects, and assignments through effective time management.

• Self-driven, capable of working independently, demonstrating a sense of urgency, and adaptable to changing directions.

• Proficient in Microsoft Office (Word, Excel, PowerPoint, and Outlook) and Adobe Acrobat PDF.

🏝️ Benefits

• The majority of work is expected to be performed remotely.

• Minimal travel may be necessary (e.g., NAIC National Meetings, in-person strategy sessions).