Note: The job is a remote job and is open to candidates in USA. Gallagher Benefit Services helps organizations make informed people and workplace decisions through benefits, wellbeing, and workforce advisory services. The Pharmacy Auditor manages and performs prescription drug claim and manufacturer rebate audits, validates compliance with contractual and regulatory requirements, collaborates with PBMs and clients to resolve findings, and prepares audit reports and recommendations.
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
Skills
- 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)
- 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
- 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
Benefits
- Comprehensive benefits programs designed to support your well-being
- Career development opportunities and ongoing learning
- A collaborative, people-first culture with accessible leadership
- The opportunity to do meaningful work with global reach and local impact
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