Note: The job is a remote job and is open to candidates in USA. Ventegra is hiring a Manager of Pharmacy Audit and Program Integrity to manage its enterprise-wide pharmacy audit strategy. The role oversees audit and program integrity initiatives, vendor performance, risk monitoring, regulatory compliance, executive reporting, and the development of a high-performing audit function.
Responsibilities
- Define and lead the enterprise-wide pharmacy audit and program integrity strategy, including audit portfolio prioritization, scalable governance frameworks, operating models, workflows, standardized documentation, execution oversight, and achievement of quality, compliance, timeliness, and financial recovery objectives
- Serve as the liaison for external pharmacy audit partners, establishing strategic oversight of vendor performance, enforcing accountability for deliverables, and ensuring alignment with internal stakeholders and organizational priorities
- Lead risk-based audit monitoring and continuous improvement efforts by leveraging claims data, audit outcomes, and external indicators to identify high-risk areas, direct root cause analysis company-wide, and implement corrective and preventive actions that address systemic issues and strengthen upstream business processes
- Deliver executive-level reporting and insights on program performance, trends, risks, financial impacts, and strategic recommendations while partnering with stakeholders to align audit strategies with enterprise priorities and risk mitigation goals
- Ensure audit programs are designed, governed, documented, and reported in compliance with all applicable state, federal, regulatory, and contractual obligations, including required submissions, reporting, audit readiness, and timely responses to regulatory inquiries
- Build and lead a high-performing audit function, including defining team structure, roles, and performance expectations, while fostering strong cross-functional collaboration across the organization
Skills
- Advanced knowledge of PBM operations, pharmacy claims processing, reimbursement models, and provider network dynamics
- Strong leadership and organizational skills, with demonstrated ability to build and scale programs and teams
- Ability to influence and collaborate effectively across all levels of the organization, including senior leadership and external partners
- Strong analytical and problem-solving skills with the ability to translate complex data into actionable insights
- Excellent communication and presentation skills, including experience delivering executive-level reporting
- Experience working with large healthcare datasets and identifying patterns indicative of fraud, waste, abuse, or operational issues
- Ability to translate business requirements into technical solutions in partnership with analytics and IT teams
- 7+ years of experience in PBM, pharmacy operations, audit, compliance, or program integrity
- Demonstrated experience leading programs, initiatives, and cross-functional teams
- Deep understanding of state and federal regulations related to pharmacy audit programs and FWA compliance
- Pharmacy claim audit: 2 years (Required)
- Pharmacy: 2 years (Required)
- PBM: 2 years (Required)
- Management: 2 years (Required)
- Doctor of Pharmacy (PharmD) preferred
- Experience developing and overseeing pharmacy or PBM audit programs strongly preferred
- Proficiency in Microsoft Office tools and experience working with data systems (SQL, Access, or similar platforms preferred)
Benefits
- 401(k)
- 401(k) matching
- AD&D insurance
- Dental insurance
- Employee assistance program
- Health insurance
- Health savings account
- Life insurance
- Paid time off
- Prescription drug insurance
- Retirement plan
- Vision insurance
- Wellness program
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