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.

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 and the ability to manage multiple projects without compromise of 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 high level of service to clients.
• Perform Prescription Drug Claim 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 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, Manager, Director, and Practice Leader as requested. Provide leadership and/or mentorship to less senior members of the audit team.
• Perform special projects or assignments, as instructed by Manager.
• Attain billable hours objective (apply acquired skills in client‑productive ways).

Required:

• College degree (experience may be considered to waive the degree requirement)
• 10+ years’ experience in pharmacy auditing, consulting, or other applicable pharmacy industry experience
• Previous PBM experience is a plus but not required
• Must demonstrate a high level of pharmacy benefit, claim, or benefit administration knowledge –…