Pharmacy Benefit Management Examiner

Examination Resources, LLC; Northern (KY); Hybrid; USD 95,000 - 140,000; Full time

Job summary

Examination Resources, LLC seeks a Senior Examiner of PBM Compliance Services to act as PBM Specialist and/or Examiner in Charge on audits for state regulators, following rules, procedures and best practices. The Senior Examiner will oversee the audit process, coordinate with PBM leadership and ensure compliant examinations across jurisdictions. The position offers remote work with periodic travel for meetings and trainings.

Qualifications

• Must have experience with PBM audits or operations.
• Knowledge of NAIC Market Regulation Handbook preferred.
• Excellent legal research and writing abilities.

Responsibilities

• Lead PBM audit examinations across multiple states and entities.
• Supervise multiple examiners and manage workflow against project plans.
• Ensure timely, accurate delivery of audit deliverables.
• Interpret state rules and enforcement requirements for PBMs.
• Collaborate with PBM leadership for program success.
• Monitor new industry compliance legislation and case law.

Skills

Legal research

Written communication

Verbal communication

Leadership

Audit/examination skills

Time management

Tools

Microsoft Office

Adobe Acrobat PDF

Job description

The Senior Examiner of Pharmacy Benefit Manager (PBM) Compliance Services will act as a PBM Specialist and/or Examiner in Charge on PBM compliance audits on behalf of state regulators, in accordance with state rules and regulations, established procedures, industry standards and best practices.

Specific Duties and Responsibilities

• Lead PBM audit examinations across various states and PBM entities in accordance with state requirements, including, but not limited to, review of pharmacy audits conducted by PBMs, pharmacy reimbursement, health plan and pharmacy contract review, analyze MFG revenue (Rx Rebates, etc.), MAC appeals, claims processing, and network adequacy, etc.
• Complete PBM examination work in the required state software platform.
• Interpret state rules and regulations pertaining to enforcement requirements of PBMs and related examinations thereof.
• Ability to supervise multiple examiners and workflow processes required for each PBM examination, This includes, but is not limited to, providing assignments to PBM staff and ensuring alignment with examination project workplan requirements and expectations.
• Ensure deadlines for all audit deliverables are met timely and accurately
• Assist in management of client and examinee company point(s) of contact relationships
• Strategize and collaborate with PBM leadership for program success.
• Assist with the monitoring and summarizing new state and federal industry compliance legislation, regulation, sub regulatory guidance, and case law, regarding PBM operations.
• Assist leadership in various PBM practice development activities, including strategic discussions, tasks, and partnerships.
• Ability to adapt to a fast-paced environment.

Required Qualifications

• Prior PBM audit or operations experience required.
• PBM industry professionals encouraged to apply (CPBS, CPhT, etc.).
• Experience completing examinations in according with NAIC Market Regulation Handbook, or experience as an attorney, accountant, auditor, examiner or analyst with a state insurance department, public accounting firm, PBM, insurance company, or state/Federal agency preferred.
• Ability to obtain the Certified Insurance Examiner (CIE), Market Conduct Management (MCM), and/or other pertinent designations relevant to the PBM industry, including continuing education requirements.
• Experience leading others.
• Exceptional legal research, writing, and verbal communication skills.
• Strong interpersonal, presentation, analytical, legal, and examination/audit skills.
• Excellent organizational skills and the ability to prioritize multiple tasks with competing priorities, projects and assignments using effective time management skills.
• Must be self-motivated, work well independently, possess a sense of urgency, and be flexible with directional changes.
• Proficient in Microsoft Office (Word, Excel, PowerPoint, and Outlook) and Adobe Acrobat PDF.
• Majority of work is anticipated to be completed remotely; minor travel maybe required (e.g., NAIC National Meetings, in person strategy sessions, etc.).

The pay range for this role is:

95,000 - 140,000 USD per year (Remote (United States))