Market Conduct Examiner - Health and PBM

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Market Conduct Examiner (Health and PBM)

Risk & Regulatory Consulting, LLC

(Regulatory Insurance)

Work from home-any US location

Position Overview
The Market Conduct Examiner will be responsible for performing reviews of major insurance companies’ operations, marketing, underwriting, mental health parity quantitative and non-quantitative treatment limits, pharmacy benefit management practices, rating, policyholder service, producer licensing, complaint handling and claims handling processes to verify compliance with states’ insurance statutes and regulations.

Specific Duties and Responsibilities

(Responsibilities may vary slightly depending on seniority level)

• Perform comprehensive, targeted and risk focused market conduct examinations to determine compliance with states’ insurance statutes and regulations on behalf of state insurance departments.
• Review and assess insurance company’s documentation and data to determine compliance with states’ insurance statutes and regulations.
• Draft examination work papers in an organized manner for supervisory review.
• Assist with the preparation of reports, exhibits, and other supporting documentation and schedules that detail a company’s compliance with insurance statutes and regulations and recommend solutions.
• Submit draft examination reports and other deliverables for supervisory review.
• Recommend/document actions to ensure compliance with insurance statutes and regulations.
• Must possess knowledge of and provide guidance of insurance laws, rules, and regulations.
• Review and analyze new, proposed, or revised laws, regulations, policies, and procedures in order to determine compliance with states’ insurance statutes and regulations and interpret their meaning and determine impact to the insurance company.
• Analyze reports and records relating to specific and overall operations of insurance companies; prepare clear, complete, concise, and informative compliance reports of condition of insurance companies for supervisory review.
• Consistently enhance knowledge of principles, practices, techniques, and methods of insurance examination and regulations; insurance laws and Insurance Commissioner’s rulings; and related Attorney General Opinions and court decisions; insurance company practices; statistical sampling procedures; basic mathematics.
  • This includes, but is not limited to, analyzing compliance pertaining to review of pharmacy audits conducted by PBMs, spread pricing, pharmacy reimbursement, dispensing fee requirements, annual reports, contract review, financial review, internal and external appeals, claims processing, and network adequacy.
• Complete examination work in the required state software platform.
  • This includes utilizing TeamMate+ and other software platforms as required.
• Ensure all deadlines presented by examination workplan schedule and PBM management are met.
  • This includes, but is not limited to, ensuring all audit deliverables are met timely and accurately, including assisting in client and examinee company point(s) of contact relationships.
• Ability to adapt to a fast-paced environment.

Requirements

• Bachelor’s Degree in Business, Risk Management, Accounting or Finance; MBA and/or professional certification/s preferred
• Minimum of 5+ years insurance experience with a State or Federal agency, insurance company, examination firm or with a public accounting firm as an internal or external auditor, adjuster, compliance professional or examiner.   
•  Insurance industry experience is a must.

• Candidates must have completed or are pursuing professional insurance designations such as AIE/CIE, MCM, AIRC, FLMI, CPCU, or CLU. 
• PC skills, including experience in using software for producing presentations, spreadsheets, and project planning (skilled in TeamMate, ACL/Access, and MS Excel, Word and Power Point).
• Demonstrated history of project management experience.
• Ability to interact with all levels including executives and senior managers.
• Strong interpersonal, presentation, analytical and examination/audit skills.
• Excellent organizational skills and the ability to prioritize multiple tasks, projects and assignments using effective time management skills.
• Strong written and verbal communication skills are required.
• Dynamic/flexible demeanor with exceptional client service skills.
• Forward-thinking leader with a collaborative focus who can consult effectively with key constituents and become recognized as a valued resource.
• Must be self-motivated, work well independently and possess a sense of urgency.
• Skilled in team building and team development.
• Flexibility for minimal travel

Preferred Qualifications

• Strong knowledge of and experience in Health Lines of Business, with an emphasis in the Affordable Care Act (ACA) and the Mental Health Parity and Addiction Equity Act (MHPAEA).

• Extensive experience with examination software TeamMate.
• Moderate experience with ACL.

Risk & Regulatory Consulting, LLC (RRC), an affiliate of RSM, is a national, leading professional services firm dedicated to providing exceptional regulatory services to clients. RRC offers services in the following regulatory areas: financial examinations, market conduct examinations, insolvency and receiverships, actuarial services and valuations, investment analysis, reinsurance expertise, market analysis and compliance, and special projects. RRC is a results-oriented firm committed to success that builds long-term relationships with its clients.  www.riskreg.com

At RSM, we offer a competitive benefits and compensation package for all our people. Learn more about our total rewards at https://rsmus.com/careers/working-at-rsm/benefits.

We believe flexibility and in-person connection both play an important role in how we work and grow. Most roles at RSM follow a hybrid workstyle, which means team members are aligned to an RSM office and come together in person when it best supports clients, teams, development or relationship-building. Some roles may be virtual or primarily on-site based on role requirements, team priorities and client needs.

All applicants will receive consideration for employment as RSM does not tolerate discrimination and/or harassment based on race; color; creed; sincerely held religious beliefs, practices or observances; sex (including pregnancy or disabilities related to nursing); gender; sexual orientation; HIV Status; national origin; ancestry; familial or marital status; age; physical or mental disability; citizenship; political affiliation; medical condition (including family and medical leave); domestic violence victim status; past, current or prospective service in the US uniformed service; US Military/Veteran status; pre-disposing genetic characteristics or any other characteristic protected under applicable federal, state or local law. 

Accommodation for applicants with disabilities is available upon request in connection with the recruitment process and/or employment/partnership. RSM is committed to providing equal opportunity and reasonable accommodation for people with disabilities. If you require a reasonable accommodation to complete an application, interview, or otherwise participate in the recruiting process, please call us at 800-274-3978 or send us an email at [email protected].

RSM does not intend to hire entry level candidates who will require sponsorship now OR in the future (i.e. F-1 visa holders). If you are a recent U.S. college / university graduate possessing 1-2 years of progressive and relevant work experience in a same or similar role to the one for which you are applying, excluding internships, you may be eligible for hire as an experienced associate.

RSM will consider for employment qualified applicants with arrest or conviction records. For those living in California or applying to a position in California, please click here for additional information.

At RSM, an employee’s pay at any point in their career is intended to reflect their experiences, performance, and skills for their current role. The salary range (or starting rate for interns and associates) for this role represents numerous factors considered in the hiring decisions including, but not limited to, education, skills, work experience, certifications, location, etc. As such, pay for the successful candidate(s) could fall anywhere within the stated range.

Compensation Range: $95,400 - $192,000