Consultant, Pharmacy Auditor

Pharmacy Auditor

The Pharmacy Auditor is an integral part of the Pharmacy Audit Team and is responsible for performing and supporting Prescription Drug Claim Audits (claims, rebates, operational, Medicare, pre/post-implementation, etc.) to validate that the coverage of a prescription drug claim, and the payment of such claim, comply with the contractual, regulatory, and custom plan guidelines. Additionally, certain audits validate the proper reimbursement of prescription rebates from a Pharmacy Benefits Manager (PBM) to a client per the contractual arrangement. This position is client facing and requires an individual who can effectively manage client expectations as well as the ability to manage multiple projects without compromising accuracy or timeliness.

Project management of Prescription Drug Claim Audits from implementation through closure. Manage and perform audits of prescription drug claim payment data to validate conformance with contractual requirements and plan specifications as assigned. Review and evaluate Administrative Services Agreement between the employer and PBM. Work with dedicated data analytics team to define and translate plan provisions for testing purposes, ensuring that scope aligns with the statement of work and client commitments. Review client-specific documentation, Summary Plan Description(s), and other documentation such as copay grids, plan literals, set-up grids, etc., to develop the audit test filters. Complete the contract summary, or assist with completion of contract summaries, as assigned. Evaluate the results of the initial claim data tests and determine valid audit samples for review and response by the PBM. Prepare PBM communications regarding test results, response expectations, and clarifications to questions. Work collaboratively with PBM to resolve exceptions, review supporting documentation, and make final claim error determination. Ensure audit timeline is adhered to and deliver a high level of service to clients. Perform Manufacturer Rebate audits as assigned. (Occasional travel to the PBM is required; 10-20% travel possible.) Prepare and present detailed audit reports which clearly articulate audit findings and recommendations to PBM and client. Maintain audit project work papers to support audit findings. Work collaboratively within the audit team, as well as with internal and external customers. Participate in team meetings, conference calls, Microsoft Teams meetings, etc. remotely with PBMs, clients, and audit team as necessary. Assist with claims data analysis and quality assurance as requested. Interact directly with clients and respond to client requests. Develop strong relationships with clients. Assist in supporting other auditors, Directors, and Practice Leader as requested. Perform special projects or assignments, as instructed by Director.

About You Required: Typically requires a University Degree or equivalent experience and minimum 5 years of prior relevant experience. Proven experience in managing client relationships and delivering high-quality client services. Strong background in pharmacy benefit management (PBM) processes and systems. Extensive experience with data analysis tools (e.g., Excel, SQL, Tableau, Power BI). Preferred: Degree in Healthcare Administration, Business, Data Analytics, or a related field. Advanced analytical and problem-solving skills with the ability to interpret complex data sets. Exceptional written and verbal communication skills, with the ability to present findings and recommendations to senior stakeholders. Strong project management skills, with the ability to manage multiple priorities and meet deadlines. Proficiency in Microsoft Office Suite (Excel, Word, PowerPoint) and data visualization tools.

Work Traits: Demonstrates in-depth knowledge of pharmacy operations, billing practices, and regulatory requirements. Strong leadership and mentoring skills, with the ability to inspire and develop team members.