Senior Examiner – Pharmacy Benefit Manager (PBM) Compliance Services

Examination Resources, LLC

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 and detailed letter of interest to ashleyogilvie@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.