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Senior Examiner – Pharmacy Benefit Manager (PBM) Compliance Services

ER provides equal employment opportunities to all applicants without regard to race, color, creed, ancestry, national origin, citizenship, sex or gender (including pregnancy, childbirth, and pregnancy-related conditions), gender identity or expression (including transgender status), sexual orientation, marital status, religion, age, disability, genetic information, service in the military, or any other protected characteristics.

We are committed to fostering an environment where differences are welcomed and valued. We encourage anyone who feels they may be qualified for a role with us to apply. We look forward to seeing how what you bring can add to our dynamic culture.

Our benefits include:

  • Competitive pay
  • Continuing education reimbursement
  • Medical, dental, vision insurance
  • HSA and FSA options
  • Short-term and long-term disability insurance
  • Life insurance
  • 401k with company match
  • Paid holidays
  • Paid sick leave
  • PTO
  • Vacation reimbursement
  • Paid parental leave
  • Paid bereavement leave
  • Mental health support
  • Monthly gym membership allowance

Job Description

Summary

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 across the nation, using state rules and regulations, established procedures, and industry standards and best practices to complete the examinations on behalf of state regulators. Required experience includes: 1) healthcare and/or insurance auditing; 2) state and federal healthcare legislation interpretation; and 3) NAIC Market Regulation Handbook. Majority of work is anticipated to be completed remotely; minor travel maybe required (e.g., NAIC National Meetings, in person strategy sessions, etc.).

 

Key Requirements

  • Lead PBM audit examinations across various states and PBM entities in accordance with state requirements.
    • This includes, but is not limited to, analyzing compliance pertaining to review of pharmacy audits conducted by PBMs, spread pricing, pharmacy reimbursement, dispensing fee requirements, annual reports, contract review, financial review, internal and external appeals, claims processing, and network adequacy.
  • Complete PBM examination work in the required state software platform.
    • This includes utilizing TeamMate+ and other software platforms as required.
  • Interpret state rules and regulations pertaining to enforcement requirements of PBMs and related examinations thereof.
    • This includes, but is not limited to, interpreting applicable state rules and regulations pertaining to the specific PBM examinations in each state.
  • Ensure all deadlines presented by examination workplan schedule and PBM management are met.
    • This includes, but is not limited to, ensuring all audit deliverables are met timely and accurately, including assisting in client and examinee company point(s) of contact relationships.
  • 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.
  • Strategize and collaborate with PBM leadership for program success.
    • This includes, but is not limited to, meeting regularly with the PBM Team to provide examination updates and to brainstorm and create strategic plans to grow PBM business.
  • Assist with PBM legal review, research, and writing.
    • This includes, but is not limited to, assisting with the monitoring and summarizing of new state and federal industry compliance legislation, regulation, sub regulatory guidance, and case law as directed. This also includes monitoring NAIC committees and subgroups with regards to PBM and pharmacy topics (e.g., related articles whitepapers, new NAIC model to establish a licensing or registration process for PBMs, etc.) and relevant E-newsletter articles.
  • Assist leadership in various PBM practice development activities, including strategic discussions, tasks, and partnerships.
  • Ability to adapt to a fast-paced environment.

Required Qualifications

  • 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.
  • Prior healthcare and/or insurance auditing experience.
  • Industry PBM professionals encouraged to apply (CPBS, CPhT).
  • 2+ year’s experience completing examinations in according with NAIC Market Regulation Handbook
  • 2+ years’ experience as an attorney, accountant, auditor, examiner or analyst with a state insurance department, public accounting firm, insurance company, or state/Federal agency.
  • 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.

Resume Submission Information

Qualified candidates are invited to submit their resumes to HR@examresources.net.

Please include:

• Current resume.
• A detailed letter of interest describing your skills and experience as they relate to the qualifications outlined in this job announcement.

We'd love to hear from you! Share what services you are interested in and how we can work together to achieve your goals.

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Atlanta, GA 30309-6197

Office: 404.816.6188
Fax: 404.816.6197

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South Jordan, UT 84095

Office: 801.562.5748

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Stuart, VA 24171

Office: 276.694.3806
Fax: 404.816.6197