Biologics Payer Audit and Accreditation Specialist

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Role Overview

The Biologics Payer Audit & Accreditation Specialist supports two closely related compliance functions within Biologics by McKesson: PBM/payer audit management and specialty pharmacy accreditation. This role is intentionally designed to be flexible. The successful candidate will bring demonstrated depth in either PBM audit management or specialty pharmacy accreditation, and will develop working proficiency in the second discipline through structured onboarding and mentorship from the respective functional owners.

On the audit side, the Specialist supports the intake, tracking, research, and response of PBM audit requests (including desk, field, real-time, and prescription validation reviews), assists in the preparation of audit appeals, and helps identify operational and documentation gaps that create recoupment risk. On the accreditation side, the Specialist supports the maintenance of URAC and ACHC accreditation across Biologics sites, including policy and SOP review, evidence collection and submission, performance measure reporting, RFI response coordination, and survey readiness activities.

The position requires working knowledge of specialty pharmacy operations, pharmacy claims adjudication, PBM provider manuals and state pharmacy audit regulations, and/or accreditation standards and evidence requirements. This position requires excellent written and verbal communication, strong documentation discipline, attention to detail, and consistent follow-up. This is a work-from-home position with approximately 15% travel.

Key Responsibilities

The weighting below reflects the expected steady-state distribution of work. Assignment weighting may flex based on the incumbent's background, business need, and accreditation or audit cycle timing.

PBM / Payer Audit Support and Risk Mitigation

• Supports intake, logging, tracking, and timely response of PBM audit requests across all Biologics sites, ensuring adherence to contractual and regulatory response deadlines.

• Researches audit findings, gathers supporting documentation, and drafts audit responses and appeals under the direction of the audit function owner.

• Assists in the analysis of audit findings and discrepancy trends by payer, site, drug, and discrepancy type to identify recurring root causes.

• Maintains audit trackers, dashboards, and reporting to support visibility for Operations, Quality, Finance, and Legal stakeholders.

• Supports interpretation and application of state pharmacy audit statutes, PBM provider manual terms, and contractual audit limitations.

• Partners with Operations to recommend workflow and documentation changes that reduce audit exposure and recoupment risk.

Accreditation and Continuous Quality Improvement

• Supports URAC and ACHC accreditation maintenance, renewal application submission, and ongoing standards compliance across accredited sites.

• Assists with gap analysis between current-state policies, SOPs, and operational practice versus applicable accreditation standards.

• Coordinates and uploads accreditation evidence, tracks required performance measure reporting, and supports RFI response development and submission.

• Supports survey readiness activities, including mock audits, staff readiness materials, documentation review, and follow-up on corrective actions.

• Assists with maintenance of accreditation documentation repositories, licensure and credentialing records, and version control.

• Supports continuous quality improvement initiatives, including quality improvement projects, corrective and preventive action (CAPA) tracking, and effectiveness monitoring.

Cross-Functional Support, Documentation, and Reporting

• Serves as a coordination point between Payer Audit, Accreditation, Quality, Operations, and Compliance stakeholders.

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

• Maintains accurate, traceable, and audit-ready documentation in accordance with internal standards and regulatory requirements.

• Supports development and delivery of staff-facing education and job aids related to audit readiness and accreditation standards.

Minimum Requirement

• Degree or equivalent and typically requires 4+ years of relevant experience.

Education

• 4-year undergraduate college degree preferred; an equivalent combination of education and directly relevant experience will be considered.

• Certified Pharmacy Technician (CPhT) preferred.

Critical Skills

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

• AND at least one of the following:

  • 2+ years of PBM audit management and/or PBM auditor experience, including audit response, appeals, and recoupment defense; OR

  • 2+ years of specialty pharmacy accreditation experience (URAC and/or ACHC), including standards interpretation, evidence submission, and survey support.

• Working knowledge of pharmacy claims adjudication, claim rejections, and associated resolutions.

• Demonstrated experience maintaining structured documentation, traceability, and corrective action follow-through.

• Knowledge of pharmacy systems, pharmacy operations, and pharmacy workflow.

Specialized Knowledge & Skills

• Specialty pharmacy experience strongly preferred.

• Working knowledge of state pharmacy audit statutes and PBM provider manual audit provisions a plus.

• Experience with accreditation management platforms (e.g., AccrediNet) or document control systems (e.g., MasterControl) a plus.

• Experience with pharmacy management systems and reporting/analytics tools (e.g., Power BI, Excel) a plus.

• Community oncology, rare disease, or limited distribution drug experience a plus.

• Ability to effectively manage internal and external stakeholder expectations in terms of service and issue resolution.

• Ability to develop collaborative internal and external relationships and partnerships.

Expected Competencies

• Detail-oriented with strong documentation and organizational discipline.

• Able to communicate effectively with pharmacists, pharmacy staff, operations leaders, auditors, and surveyors.

• Good problem-solving and decision-making skills.

• Strong interpersonal and written communication skills.

• Self-motivated and results-oriented; requires limited direction or direct supervision.

• Effectively manages multiple workstreams with competing deadlines.

• Team player with the ability to manage timelines and goals.

• Strong analytical skills.

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

• Proficient in Microsoft Office; technologically savvy.

Working Conditions

Environment (e.g., office, manufacturing, warehouse)

• General office environment; Work From Home.

• Approximately 15% travel, including travel to Biologics sites for survey support, mock audits, and readiness activities.

We are proud to offer a competitive compensation package at McKesson as part of our Total Rewards. This is determined by several factors, including performance, experience and skills, equity, regular job market evaluations, and geographical markets. The pay range shown below is aligned with McKesson's pay philosophy, and pay will always be compliant with any applicable regulations. In addition to base pay, other compensation, such as an annual bonus or long-term incentive opportunities may be offered. For more information regarding benefits at McKesson, please click here.

Our Base Pay Range for this position

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