Auditor of Pharmacy Benefit Management

Overview

This role involves serving as a Pharmacy Auditor responsible for performing and supporting Prescription Drug Claim Audits, including claims, rebates, operational, Medicare, and pre/post-implementation audits. The primary objective is to validate that prescription drug claim coverage and payments comply with contractual, regulatory, and custom plan guidelines. Some audits also verify proper reimbursement of prescription rebates from Pharmacy Benefits Managers (PBMs) to clients per contractual agreements. This position requires client interaction and the ability to manage multiple projects accurately and timely.

Responsibilities

• Manage Prescription Drug Claim Audit projects from implementation through closure.
• Perform audits of prescription drug claim payment data to ensure compliance with contractual requirements and plan specifications.
• Review and evaluate Administrative Services Agreements between employers and PBMs.
• Collaborate with data analytics teams to define and translate plan provisions for testing, ensuring alignment with statements of work and client commitments.
• Review client-specific documentation such as Summary Plan Descriptions, copay grids, plan literals, and set-up grids to develop audit test filters.
• Complete or assist in completing contract summaries as assigned.
• Evaluate initial claim data test results and select valid audit samples for PBM review.
• Prepare communications to PBMs regarding test results, response expectations, and clarifications.
• Work collaboratively with PBMs to resolve exceptions, review supporting documentation, and determine final claim errors.
• Adhere to audit timelines and deliver high-quality service to clients.
• Perform Manufacturer Rebate audits as assigned; occasional travel to PBM locations may be required (10-20%).
• Prepare and present detailed audit reports articulating findings and recommendations to PBMs and clients.
• Maintain audit project work papers to support findings.
• Collaborate within the audit team and with internal and external customers.
• Participate in meetings and conference calls with PBMs, clients, and audit teams.
• Assist with claims data analysis and quality assurance as needed.
• Interact directly with clients, respond to requests, and develop strong client relationships.
• Support other auditors, Directors, and Practice Leaders as requested.
• Perform special projects or assignments as directed by management.

Requirements

• College degree preferred; relevant experience may waive this requirement.
• Minimum of 5 years’ experience in prescription drug claim auditing, consulting, or related pharmacy industry roles.
• Previous PBM experience is a plus but not required.
• Strong knowledge of pharmacy benefits, claims, or benefit administration; Medicare benefits experience is highly desirable.
• Proficiency with Microsoft Office Suite (Word, Excel, PowerPoint, Outlook, Teams).
• Excellent oral and written communication skills.
• Strong organizational and time management abilities.
• Personable communication style with a positive outlook and self-confidence.
• Ability to multitask and adapt to changing priorities without losing focus.
• Attention to detail and ability to clearly document reasoning and conclusions.
• Self-directed with minimal supervision; capable of managing multiple projects to meet deadlines.
• Team player with a strong work ethic.

Compensation and Benefits

• Competitive and comprehensive compensation package with salary influenced by experience, education, geography, skill set, and other factors.
• Core benefits include:
  • Medical, dental, and vision plans starting from day one.
  • Life and accident insurance.
  • 401(k) and Roth options.
  • Tax-advantaged accounts (HSA, FSA).
  • Educational expense reimbursement.
  • Paid parental leave.
• Additional benefits may include:
  • Digital mental health services.
  • Flexible work hours (varies by office and role).
  • Training programs.
  • Charitable matching gift program.
• Benefits details apply primarily to full-time positions; part-time benefits will be provided during the selection process.

Location

• This position may require occasional travel to PBM locations (approximately 10-20%).

Equal Employment Opportunity

The organization is committed to providing equal employment opportunities without discrimination based on race, color, religion, creed, gender (including pregnancy status), sexual orientation, gender identity or expression, marital or parental status, age, national origin, ancestry, disability, medical condition, genetic information, veteran or military status, citizenship status, or any other protected characteristic under applicable laws. Reasonable accommodations will be made for qualified individuals with disabilities unless it imposes undue hardship on business operations.