Pharmacy Benefit Management Examiner

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Examination Resources, LLC

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 2002

💼 Consulting

🛡️ Insurance

🏛️ Government

Consulting • Insurance • Government

Examination Resources, LLC is a woman-owned regulatory consulting firm (WOSB) that delivers specialized, regulator-only consulting services to state and federal insurance regulators across the U. S. Since 2002, ER has focused on insurance oversight and consumer protection, offering actuarial and financial analysis, financial examinations, health consulting, IT consulting, market conduct reviews, MLR and PBM compliance, receivership and other specialized regulatory services. The firm emphasizes avoidance of conflicts of interest by serving only regulators, is an approved GSA vendor, and highlights a track record of 2,500+ projects, 160+ focused talent, and support for 45+ regulators.

📋 Description

• Lead PBM audit examinations across various states and PBM entities in accordance with state requirements • Review pharmacy audits conducted by PBMs, pharmacy reimbursement, health plan and pharmacy contracts, MFG revenue such as Rx rebates, MAC appeals, claims processing, and network adequacy • Complete PBM examination work in the required state software platform • Interpret state rules and regulations pertaining to PBM enforcement requirements and examinations • Supervise multiple examiners and workflow processes for each PBM examination • Assign work to PBM staff and ensure alignment with examination workplan requirements and expectations • Ensure audit deliverables are completed timely and accurately • Assist in managing client and examinee company points-of-contact relationships • Strategize and collaborate with PBM leadership for program success • Monitor and summarize new state and federal compliance legislation, regulations, sub-regulatory guidance, and case law regarding PBM operations • Assist leadership with PBM practice development activities, strategic discussions, tasks, and partnerships • Adapt to a fast-paced environment

🎯 Requirements

• Prior PBM audit or operations experience required • PBM industry professionals encouraged to apply (CPBS, CPhT, etc.) • Experience completing examinations in accordance with the NAIC Market Regulation Handbook, or experience as an attorney, accountant, auditor, examiner, or analyst with a state insurance department, public accounting firm, PBM, insurance company, or state/Federal agency preferred • 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 • Experience leading others • Exceptional legal research, writing, and verbal communication skills • Strong interpersonal, presentation, analytical, legal, and examination/audit skills • Excellent organizational skills and ability to prioritize multiple tasks with competing priorities, projects, and assignments using effective time management skills • Self-motivated, able to 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

🏖️ Benefits

• Majority of work anticipated to be completed remotely • Minor travel may be required (e.g., NAIC National Meetings, in-person strategy sessions)