Pharmacy Auditor

Introduction

At Gallagher Benefit Services, you’re a trusted partner to organizations navigating some of their most important people decisions. We help clients build better workplaces, where people feel supported, empowered, and inspired to thrive. Whether it’s shaping benefit strategies, designing wellbeing programs, or advising on workforce challenges, the work you do here creates meaningful change for businesses and the people who power them.

We’re a community of bold explorers, trusted experts, and compassionate partners; working side by side to solve problems, and shape the future of work. Here, curiosity is encouraged, collaboration is second nature, and your ideas have room to grow. If you’re looking for a place where your contribution matters and where you can help build a better world of work; think of Gallagher.

Overview

The Pharmacy Auditor is an integral part of the Pharmacy Audit Team and is responsible for performing and supporting Prescription Drug Claim Audits (claims, rebates, operational, Medicare, pre/post-implementation, etc.) to validate that the coverage of a prescription drug claim, and the payment of such claim, comply with the contractual, regulatory, and custom plan guidelines. Additionally, certain audits validate the proper reimbursement of prescription rebates from a Pharmacy Benefits Manager (PBM) to a client per the contractual arrangement.

This position is client facing and requires an individual who can effectively manage client expectations as well as the ability to manage multiple projects without compromising accuracy or timeliness.

Project management of Prescription Drug Claim Audits from implementation through closure.

Manage and perform audits of prescription drug claim payment data to validate conformance with contractual requirements and plan specifications as assigned.

Review and evaluate Administrative Services Agreement between the employer and PBM.

Work with dedicated data analytics team to define and translate plan provisions for testing purposes, ensuring that scope aligns with the statement of work and client commitments. Review client-specific documentation, Summary Plan Description(s), and other documentation such as copay grids, plan literals, set-up grids, etc., to develop the audit test filters.

Complete the contract summary, or assist with completion of contract summaries, as assigned.

Evaluate the results of the initial claim data tests and determine valid audit samples for review and response by the PBM.

Prepare PBM communications regarding test results, response expectations, and clarifications to questions.

Work collaboratively with PBM to resolve exceptions, review supporting documentation, and make final claim error determination.

Ensure audit timeline is adhered to and deliver a high level of service to clients.

Perform Manufacturer Rebate audits as assigned. (Occasional travel to the PBM is required; 10-20% travel possible.)

Prepare and present detailed audit reports which clearly articulate audit findings and recommendations to PBM and client.

Maintain audit project work papers to support audit findings.

Work collaboratively within the audit team, as well as with internal and external customers.

Participate in team meetings, conference calls, Microsoft Teams meetings, etc. remotely with PBMs, clients, and audit team as necessary.

Assist with claims data analysis and quality assurance as requested.

Interact directly with clients and respond to client requests. Develop strong relationships with clients.

Assist in supporting other auditors, Directors, and Practice Leader as requested.

Perform special projects or assignments, as instructed by Director.

How you'll make an impact

Responsible for the day-to-day account management of largest and/or most complex client accounts. Builds, expands, and solidifies relationships with existing clients at all levels within the company and leads appropriate resources to address the client's risk/capital management needs. Secures existing business and drives the sale of additional services and coverage levels. Has retention goals. Cultivates relationships with most senior buyer in the client organization as well as with day-to-day client representatives and buyers.

Has retention goals for assigned group of accounts. Prepare and negotiate fee-based pricing of services, ensuring account profitability in a value-based approach for the scope of service and costs associated with the client service agreement.

About You

Required: Bachelor's degree and 5 or more years client coordination and/or claims management experience OR High School degree and 10 years client coordination and/or claims management experience. License required. Able and willing to travel approximately 25% of the time.

Compensation and benefits

At Gallagher, we believe supporting our colleagues goes far beyond the role itself. For more information, visit our Benefits page.

Competitive compensation

Comprehensive benefits programs designed to support your well-being

Career development opportunities and ongoing learning

A collaborative, people-first culture with accessible leadership

The opportunity to do meaningful work with global reach and local impact

At Gallagher, we are dedicated to building an inclusive and authentic workplace. If your past experience doesn’t align perfectly, we encourage you to join our Talent Community to stay connected to additional career opportunities. At times, we will consider transferable skills from previous roles.

Gallagher is an affirmative action/equal opportunity employer (Minorities/Females/Veterans/Disabled)