Senior Pharmacy Auditor

Gallagher•Rolling Meadows, IL

33d

About The Position

The Senior Pharmacy Auditor is an integral member of the Pharmacy Audit Team, performing and supporting prescription drug claim audits—including claims, rebate, operational, Medicare, and pre- and post-implementation audits. The role validates whether prescription drug claim coverage and payment comply with contractual, regulatory, and custom plan guidelines, and may also verify that a Pharmacy Benefits Manager (PBM) properly reimburses prescription rebates to clients under contractual arrangements. This is a client-facing position requiring effective client expectation management and the ability to handle multiple projects while maintaining accuracy and timeliness. The Senior Pharmacy Auditor manages audits from implementation through closure, reviews plan and contract documentation, works with data analytics colleagues to define testing, evaluates test results, and coordinates with PBMs to resolve exceptions and determine claim errors. The role prepares and presents audit reports and maintains supporting work papers. It also involves client interaction, collaboration with internal and external stakeholders, assistance to other auditors and leaders, and special assignments as directed. Manufacturer rebate audits may require occasional travel to PBMs, with 10–20% travel possible.

Requirements

Typically, a university degree or equivalent experience and a minimum of 5 years of relevant experience.
Proven experience managing client relationships and delivering high-quality client service.
Strong background in pharmacy benefit management (PBM) processes and systems.
Extensive experience with data analysis tools such as Excel, SQL, Tableau, or Power BI.

Nice To Haves

Degree in Healthcare Administration, Business, Data Analytics, or a related field.
Advanced analytical and problem-solving skills, including the ability to interpret complex data sets.
Exceptional written and verbal communication skills and ability to present findings and recommendations to senior stakeholders.
Strong project management skills and ability to manage multiple priorities and meet deadlines.
Proficiency in Microsoft Office Suite, including Excel, Word, and PowerPoint, and data visualization tools.
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.

Responsibilities

Project-manage prescription drug claim audits from implementation through closure.
Manage and perform audits of prescription drug claim payment data to validate compliance with contractual requirements and plan specifications.
Review and evaluate Administrative Services Agreements between employers and PBMs.
Work with the data analytics team to translate plan provisions into testing requirements and ensure audit scope aligns with the statement of work and client commitments.
Review client documentation, including Summary Plan Descriptions, copay grids, plan literals, and setup grids, to develop audit test filters.
Complete or assist with contract summaries.
Evaluate initial claim data test results and determine valid audit samples for PBM review and response.
Prepare PBM communications about test results, response expectations, and clarifications.
Collaborate with PBMs to resolve exceptions, review supporting documentation, and make final claim error determinations.
Ensure audit timelines are met and provide a high level of client service.
Perform manufacturer rebate audits as assigned.
Prepare and present detailed audit reports articulating findings and recommendations to PBMs and clients.
Maintain audit project work papers supporting audit findings.
Collaborate with the audit team and internal and external customers.
Participate remotely in team meetings, conference calls, and Microsoft Teams meetings with PBMs, clients, and the audit team as necessary.
Assist with claims data analysis and quality assurance as requested.
Interact directly with clients, respond to client requests, and build strong client relationships.
Support other auditors, Directors, and the Practice Leader as requested.
Perform special projects or assignments as instructed by the Director.