Market Regulation PBM Compliance Consultant

We are the leading provider of professional services to the middle market globally, our purpose is to instill confidence in a world of change, empowering our clients and people to realize their full potential. Our exceptional people are the key to our unrivaled, inclusive culture and talent experience and our ability to be compelling to our clients. You’ll find an environment that inspires and empowers you to thrive both personally and professionally. There’s no one like you and that’s why there’s nowhere like RSM.

Market Regulation PBM Compliance Consultant

Position is work from home

Risk & Regulatory Consulting, LLC

Specific Duties and Responsibilities:

• Assess PBM and insurance company’s (Entity) compliance with state and federal laws.  Understanding of the Entities operations in relation to the insurance transactions and pharmaceutical supply chain is essential.  
• Evaluate Entities contracts with health plans and pharmacies to determine if they contain discriminatory or non-compliant provisions
• Perform comparative reviews of MAC pricing lists/contracts
• Conduct reviews of Entities’ insurance transactions with consumers to determine compliance with state and federal laws.  
• Conduct reimbursement methodology reviews, pharmacy audit reviews and network adequacy reviews
• Validate and analyze the quarterly and annual data reports
• Monitor Entities marketplace activities and trends
• Document in writing findings and reports of examinations, as needed
• Prepare and present training on such topics
• Participate in practice development activities with state and federal state agencies

Requirements:

• Must have 3-5 years of insurance company and/or PBM operational and/or compliance/internal audit experience and prior consulting experience in healthcare, managed care, or PBM industries and working knowledge of Pharmacy Benefit Managed Care business or PBM experience
• Bachelor’s Degree in Business, Risk Management, Accounting, Finance or applicable fields
• Ability to interact effectively across department lines and with all levels of management
• Must understand the fundamentals of health insurance and the pharmaceutical supply chain, MAC pricing, national average drug acquisition cost (NADAC) reimbursements, spread pricing, and pharmacy claims and balancing clinical, regulatory, pharmaceutical industry issues.
• Proficient at using Microsoft Office (Word, Excel, Access, PowerPoint, and Outlook)
• Effective written and oral communication skills
• Regulatory experience is a plus
• Strong analytical abilities and attention to detail
• Self-directed and the ability to problem solve in a positive, productive manner
• Strong communication skills, collaborative, adaptable to changing priorities and ability to execute on tight deadlines Strong team orientation and the ability to work with a variety of people
• Must be comfortable doing presentations and conducting phone calls with …