PBM Audit Manager

Job Description

Job Description

Description:

Job Title:? Pharmacy Audit Manager?- Billing & Insurance Claims

FLSA Status:? Non-Exempt?

Reports to:? Director of Regulatory and Compliance ?

Hourly/Salary:? Salary

Department:? Compliance?

Location: Cherry Hill,?NJ

MedWiz is the premier pharmacy partner for long-term-care communities that share our commitment and priority to patient-care first. We have transformed the conventional medication management process by being high-touch and patient -focused. At MedWiz we work tirelessly to streamline the often-disjointed communication process between the integral stakeholders in the medication ordering and administration life-cycle. We accomplish this by simplifying processes, educating and communicating frequently. Our comprehensive technology solutions and breadth of pharmaceutical products and services – allow us to be nimble and creative in offering the right service everyone of our unique customer needs. MedWiz understands its customers’ needs and has the industry’s highest standards – with strict adherence to federal and state regulations.

SUMMARY

The Audit Manager is responsible for managing, coordinating, and overseeing all audit-related activities involving pharmacy benefit manager (PBMs), third-party payers, Medicare, Medicaid, and DME claims. This role ensures accuracy and compliance in pharmacy billing practices, manage overpayment and recoupment processes, and implements corrective actions to minimize financial and regulatory risk.

ESSENTIAL FUNCTIONS

To perform this job successfully, an individual must be able to perform each essential function satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Predictable, reliable, and punctual attendance is an essential function of the job role.

• Serve as the primary liaison for all PBM, Medicare, Medicaid, and third-party audits.
• Review and analyze audit requests, documentation, and findings to ensure accuracy and compliance with payer and regulatory requirements
• Manage and respond to desk and onsite audits in a timely and professional manner.
• Identify audit trends and develop preventative strategies to reduce future findings
• Collaborate with billing teams to ensure claims are submitted according to payer-specific guidelines
• Review, validate, and manage overpayment notifications and recoupment from payers
• Coordinate internal reviews to determine the accuracy of alleged discrepancies
• Maintain accurate documentation for DME dispensing, delivery, and billing
• Support audits specific to DME services and implement corrective actions when necessary
• Prepare monthly and quarterly audit reports
• Conduct root cause analysis of audit outcomes and develop corrective and preventative action plans
• Collaborate with operations, compliance, and clinical teams to strengthen billing accuracy and regulatory adherence
• Provide education and training to staff on billing compliance and audit preparedness

PHYSICAL DEMANDS:

The physical demands and work environment described here are representative of those an employee encounters while performing the essential functions of this job.

The regular work schedule for this position is approximately 40 hours per week (Monday-Friday) and may require additional hours/overtime as necessary. Must regularly lift and/or move up to 20 pounds. Specific vision abilities required by this job include: Close vision, Distance vision, Peripheral vision, Depth perception, Ability to adjust focus and Ability to match or detect differences between colors, including shades of color and brightness. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand, bend, and walk.

QUALIFICATIONS

• High School Diploma or GED required
• Bachelor’s degree in Healthcare Administration, Business, or related field preferred
• NJ Pharmacy Technician license
• Certified Pharmacy Technician (CPhT) preferred
• 3-5 years of experience in pharmacy auditing or billing
• Strong knowledge of PBM contracts, Medicare Part D, Medicaid billing, and DME regulations
• Excellent analytical and problem-solving skills
• Strong understanding of pharmacy claim adjudication and billing workflows
• Exceptional organizational skills and attention to detail
• Proficiency with pharmacy management systems and Microsoft Office (Excel, Word, Outlook)
• Strong communication and leadership ability