RemotePrimarily remote; minor travel may be required for meetings and in-person strategy sessions.
Risk & ComplianceRegulatory Compliance & Ethics
About the job
Requirements
Prior pharmacy benefit manager audit or operations experience is required.
Experience completing examinations in accordance with the NAIC Market Regulation Handbook, or experience as an attorney, accountant, auditor, examiner, or analyst with a state insurance department, public accounting firm, pharmacy benefit manager, insurance company, or state or federal agency is preferred.
Ability to obtain the Certified Insurance Examiner, Market Conduct Management, or other pertinent pharmacy benefit manager industry designations, including continuing education requirements.
Experience leading others.
Proficient in Microsoft Office, including Word, Excel, PowerPoint, and Outlook, and Adobe Acrobat PDF.
Ability to organize and prioritize multiple tasks, projects, and assignments with competing priorities using effective time management.
Ability to work independently, remain self-motivated and flexible with directional changes, and maintain a sense of urgency.
Responsibilities
Lead pharmacy benefit manager audit examinations across states and pharmacy benefit manager entities in accordance with state requirements, including reviewing pharmacy audits conducted by pharmacy benefit managers, pharmacy reimbursement, health plan and pharmacy contracts, manufacturer revenue such as prescription drug rebates, maximum allowable cost appeals, claims processing, and network adequacy.
Complete pharmacy benefit manager examination work in the required state software platform.
Interpret state rules and regulations concerning enforcement requirements for pharmacy benefit managers and related examinations.
Supervise multiple examiners and examination workflows, assign work to pharmacy benefit manager staff, and ensure alignment with examination work plans and expectations.
Ensure audit deliverables are completed accurately and on time.
Assist with managing relationships with client and examinee company points of contact.
Collaborate with pharmacy benefit manager leadership on program success.
Assist with monitoring and summarizing new state and federal compliance legislation, regulations, sub-regulatory guidance, and case law concerning pharmacy benefit manager operations.
Assist leadership with pharmacy benefit manager practice development, including strategic discussions, tasks, and partnerships.
Desired Qualifications
Experience completing examinations in accordance with the NAIC Market Regulation Handbook, or experience as an attorney, accountant, auditor, examiner, or analyst with a state insurance department, public accounting firm, pharmacy benefit manager, insurance company, or state or federal agency.
Position Overview
The Senior Examiner of Pharmacy Benefit Manager (PBM) Compliance Services will act as a PBM Specialist and/or Examiner in Charge on PBM compliance audits on behalf of state regulators, in accordance with state rules and regulations, established procedures, industry standards and best practices.
Specific Duties and Responsibilities
· Lead PBM audit examinations across various states and PBM entities in accordance with state requirements, including, but not limited to, review of pharmacy audits conducted by PBMs, pharmacy reimbursement, health plan and pharmacy contract review, analyze MFG revenue (Rx Rebates, etc.), MAC appeals, claims processing, and network adequacy, etc.
· Complete PBM examination work in the required state software platform.
· Interpret state rules and regulations pertaining to enforcement requirements of PBMs and related examinations thereof.
· Ability to supervise multiple examiners and workflow processes required for each PBM examination, This includes, but is not limited to, providing assignments to PBM staff and ensuring alignment with examination project workplan requirements and expectations.
· Ensure deadlines for all audit deliverables are met timely and accurately
· Assist in management of client and examinee company point(s) of contact relationships
· Strategize and collaborate with PBM leadership for program success.
· Assist with the monitoring and summarizing new state and federal industry compliance legislation, regulation, sub regulatory guidance, and case law, regarding PBM operations.
· Assist leadership in various PBM practice development activities, including strategic discussions, tasks, and partnerships.
· Ability to adapt to a fast-paced environment.
Required Qualifications
· Prior PBM audit or operations experience required.
· PBM industry professionals encouraged to apply (CPBS, CPhT, etc.).
· Experience completing examinations in according with NAIC Market Regulation Handbook, or experience as an attorney, accountant, auditor, examiner or analyst with a state insurance department, public accounting firm, PBM, insurance company, or state/Federal agency preferred.
· Ability to obtain the Certified Insurance Examiner (CIE), Market Conduct Management (MCM), and/or other pertinent designations relevant to the PBM industry, including continuing education requirements.
· Experience leading others.
· Exceptional legal research, writing, and verbal communication skills.
· Strong interpersonal, presentation, analytical, legal, and examination/audit skills.
· Excellent organizational skills and the ability to prioritize multiple tasks with competing priorities, projects and assignments using effective time management skills.
· Must be self-motivated, work well independently, possess a sense of urgency, and be flexible with directional changes.
· Proficient in Microsoft Office (Word, Excel, PowerPoint, and Outlook) and Adobe Acrobat PDF.
· Majority of work is anticipated to be completed remotely; minor travel maybe required (e.g., NAIC National Meetings, in person strategy sessions, etc.).