Pharmacy Benefit Audit Specialist
Pharmacy Benefit Audit Specialist
Job Category: Client Support
PillarRx Consulting is currently seeking a Pharmacy Benefit Audit Specialist to join our team. This role supports clients by leveraging PillarRx’s proprietary software and PBM claims data to analyze claims data, identify findings, and develop / present findings to the clients to ensure PBMs are processing pharmacy claims in alignment with the clients’ contract. The Pharmacy Benefit Audit Specialist will build, develop, and grow business relationships vital to the success of each audit project, which includes implementing, executing, and finalizing with strict deadlines. They will also direct and manage project development from beginning to end which can include a variety of different types of PBM audits depending on the client audit requirements.
Combining nearly 50 years of pharmacy benefit management experience, PillarRx is a leading firm dedicated to delivering pharmacy benefit consulting, auditing, and copay assistance services. PillarRx assists health plans, municipalities, self-funded entities, business coalitions and Taft Hartley plans.
Our qualified professionals lead all aspects of the pharmacy benefit program, helping our customers save money, minimize compliance risks, and refine their PBM contract. We provide best-in-class, value-based pharmacy solutions utilizing 100% review of your pharmacy claims. Our practical compliance guidance can help you maximize your financial outcomes, eliminate pharmaceutical waste & abuse, and increase member satisfaction.
Essential Duties and Functions:
- Conducts Data Analysis for pharmacy benefit and contractual audits surrounding pharmacy claims. PBM audits can include, but are not limited to rebates, eligibility, pricing, plan design, CMS Data Validation, and performance guarantee review.
- Includes gathering, implementing, executing, and finalizing audit rules and requirements from clients and PBMs into proprietary systems.
- Assists with review of PBM contract(s) and contribute suggestions for improvement, based on knowledge of industry
- Leverages the company’s reporting systems to conceptualize, design, and distribute both operational and analytical reports focused on pharmacy utilization and cost
- Assists with developing, documenting, and evaluating the business requirements associated with data flows to and from the PBM and other vendors
- Identifying issues and resolutions, and consulting management on potential solutions to facilitate critical decisions.
- Generate audit reports and consult with client on the findings.
- Works effectively on multiple client assignments or projects simultaneously
- Plan, schedule, and track project timelines, milestones, and deliverables.
- This position will include job duties that require risk designations for access to Electronic Protected Health Information (PHI) in the course of their job responsibilities
Other duties may be assigned.
- Minimum of one to five years’ work experience in healthcare or health insurance fields, with a focus on pharmacy claims processing and pharmacy benefits related activities
- Ability to build and maintain strong, collaborative working relationships with multiple business units across the company
- Strong communication skills (written and verbal)
- Ability to maintain a high level of confidentiality
- Proficient with MS Office Suite
- Associate degree or higher
- Direct PBM claims auditing experience within a PBM and/or Health Plan.
- Pharmacy Technician Certification (CPhT) and/or pharmacy work experienced
Raegan Osborn, [email protected]
We are an Equal Opportunity Employer. We take pride in the diversity of our team and seek diversity in our applicants.