Back to jobs
Job Description
Conduct on‑site and desk audits of pharmacy providers to verify compliance with Pharmacy Benefit Management (PBM) agreements. Review pharmacy claims and dispensing records for accuracy and regulatory adherence. Analyze large datasets to identify trends, anomalies, and potential risk indicators. Research and report on health benefit utilization trends; develop provider profiling criteria. Identify cost‑containment opportunities and support financial recovery efforts. Prepare audit reports outlining findings, financial impact, and corrective actions. Communicate findings to internal teams and pharmacy providers; support remediation efforts. Serve as a subject‑matter expert on pharmacy operations, claims adjudication, and PBM reimbursement.