Auditor of Pharmacy Benefit Management

Gallagher • Rolling Meadows, IL

1d • Hybrid

About The Position

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.

Requirements

• College degree (experience may be considered to waive the degree requirement)
• 5+ years’ experience in prescription drug claim auditing, consulting, or other applicable pharmacy industry experience
• Must demonstrate a high level of pharmacy benefit, claim, or benefit administration knowledge - Medicare benefits experience is a strong plus
• Proficient in the use of Microsoft Office Suite of programs (Word, Excel, PowerPoint, Outlook, Teams)
• Excellent oral and written communication skills are required
• Excellent organizational and time management skills
• Personable communication style, positive outlook, and self-confidence
• Ability to multi-task and acclimate to changing priorities without losing focus
• Attention to detail and ability to clearly explain thought process in reaching documented conclusions
• Self-directed individuals who require little supervision and can manage multiple projects effectively to ensure deadlines are met
• Team player with a strong work ethic

Nice To Haves

• Previous PBM experience is a plus but not required

Responsibilities

• 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.

Benefits

• Medical/dental/vision plans, which start from day one!
• Life and accident insurance
• 401(K) and Roth options
• Tax-advantaged accounts (HSA, FSA)
• Educational expense reimbursement
• Paid parental leave
• Digital mental health services (Talkspace)
• Flexible work hours (availability varies by office and job function)
• Training programs
• Gallagher Thrive program – elevating your health through challenges, workshops and digital fitness programs for your overall wellbeing
• Charitable matching gift program

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree