PBM Audit & Specialty Pharmacy

ZealHire Inc.; Northern (KY); Hybrid; USD 60,000 - 90,000; Full time

Job summary

PBM Audit & Specialty Pharmacy is seeking a Temporary Audit & Appeals Specialist to manage PBM, payer, and payment integrity audits. The role handles high-volume requests, ensures regulatory compliance, and supports audit appeals and recoupment risk minimization.

Ideal candidates have 3+ years in specialty pharmacy or PBM audits, strong Excel/Outlook skills, and excellent written communication. This position requires Cleveland or EST timezone alignment and a Monday–Friday schedule.

Qualifications

• 3+ years in specialty pharmacy or PBM audits.
• Experience reviewing pharmacy claims and payer requirements.
• Strong written communication and documentation skills.
• Advanced Microsoft Excel, Word, and Outlook proficiency.

Responsibilities

• Coordinate and administer PBM audits and payer reviews.
• Process, track, and respond to audit requests to minimize recoupment risk.
• Prepare audit appeals and track outcomes.
• Maintain regulatory and payer compliance.
• Manage high-volume audit workload (>1,700 requests annually).

Skills

PBM audits

Revenue integrity

Payer operations

Excel/Word/Outlook

Documentation

Multitasking

Analytical thinking

Tools

Excel

Word

Outlook

Job description

PBM Audit & Specialty Pharmacy | JPC-8587

USC/GCNeed LinkedIn, VISA DL2 months project

Interview Mode: Teams Video

Work schedule (days & time): must be able to work Monday - Friday 8:30am - 5pm EST Timezone

The Temporary PBM Audit & Appeals Specialist is responsible for the administration and coordination of pharmacy benefit manager (PBM), payer, and payment integrity audits. This role serves as the primary operational resource for receiving, processing, tracking, researching, responding to, and closing audit requests while ensuring compliance with contractual, regulatory, and payer requirements.

The Specialist manages a high-volume audit environment consisting of prescription validation reviews, desk audits, field audits, real-time audits, and other payer review activities. The position also supports preparation of audit appeals, objections to audit scope, documentation collection, and audit outcome tracking designed to minimize recoupment risk and protect organizational revenue. Audit activity exceeds 1,700 requests annually and requires strong organization, regulatory knowledge, and attention to detail.

Primary Responsibilities:

Required

• 3+ years of experience in specialty pharmacy, PBM audits, pharmacy compliance, payer operations, revenue integrity, or related healthcare operations.
• Experience reviewing pharmacy claims, prescription documentation, and payer requirements.
• Strong written communication and documentation skills.
• Advanced Microsoft Excel, Word, and Outlook proficiency.
• Ability to manage multiple concurrent deadlines with minimal supervision.
• Strong analytical, organizational, and problem-solving skills.

Preferred

• Specialty pharmacy experience.
• Experience with PBM audits, payment integrity reviews, or prescription validation audits.
• Familiarity with state pharmacy audit laws and PBM provider manuals.
• Experience developing audit appeals and recoupment disputes.
• Knowledge of specialty pharmacy accreditation standards (URAC and/or ACHC).

$000,000 – $000,000 Salary range is not shown on the candidate portal