Data Validation Audit Specialist

Built on meritocracy, our unique company culture rewards self-starters and those who are committed to doing what is best for our customers.

This role supports clients by leveraging our proprietary software and PBM claims data to analyze claims data, identify findings, and develop / present findings to the clients to ensure PBMs are processing pharmacy claims in alignment with the clients’ contract.   The Data Validation Audit Specialist will develop and grow business relationships vital to the success of each audit project, which includes implementing, executing, and finalizing with strict deadlines. They will also manage project development from beginning to end which can include a variety of different types of PBM audits depending on the client audit requirements.  They will additionally begin to mentor team members and begin testing new resource enhancements.

Our qualified professionals lead all aspects of the data validation audit. The DV Standards assess an organization’s information systems capabilities and its processes for collecting, storing, compiling, and reporting data. Auditors use the CMS Reporting Guidelines to assess whether a plan met each of major standards for each Reporting Section. We provide best-in-class, value-based pharmacy solutions utilizing 100% review of your data validation files. Our practical compliance guidance can help you maximize your financial outcomes, eliminate pharmaceutical waste & abuse, and increase member satisfaction.

Essential Duties and Functions: include the following.  Other duties may be assigned.

• Executes Medicare Part C & D Data Validations audits following CMS Data Validation Procedure Manual and timelines to complete the audit accurately and timely  
• Reviews data files, policy & procedures and other documentation supplied by the client to ensure compliance with CMS Part C & D reporting requirements  
• Reviews audit findings and scores with client and submits to CMS via the Examination Engagement Standards (EES) form
• Understands CMS Medicare Part C & D reporting requirements and technical specifications to lead and complete Data Validation (DV) audits. Which includes:
  • Part C Reporting Sections: Grievance, Organization Determinations and Reconsiderations, Special Needs Plan Management (SNP). 
  • Part D Reporting Sections: Grievance, Medication Therapy Management Program (MTMP), Coverage Determination, Redetermination, and Reopenings, Improving Drug Utilization Review Controls (IDURC)
• Maintains CMS Medicare Part C & D knowledge to best support annual Data Validation audits for Medicare Advantage and Prescription Drug Plans
• Abide by the general standards set forth by CMS for each Part C & D reporting section to determine whether the Medicare Advantage or Prescription Drug Plans data reported to CMS is accurate, valid and reliable
• Conducts Data Analysis for CMS Data Validation, pharmacy benefit and contractual audits surrounding pharmacy claims. CMS/PBM audits can include but are not limited to Part C & D Data Validation, Rebates, Eligibility, Pricing, Plan design, and Performance Guarantee review
• Assists with review of all CMS documentation and review of all designated entities supporting documentation
• Leverages the company’s reporting systems to conceptualize, design, and document all audit findings
• Assists with developing, documenting, and evaluating the business requirements associated with data flows between the client, PBM and other vendors
• Identifying issues and resolutions, and consulting management on potential solutions to facilitate critical decisions.
• Generate audit reports and consult with client on the findings and upload all findings to CMS.
• Works effectively on multiple client assignments or projects simultaneously
• Plan, schedule, and track project timelines, milestones, and deliverables.
• This position will include job duties that require risk designations for access to Electronic Protected Health Information (PHI) in the course of their job responsibilities
• Other duties may be assigned.

Competencies:

The below behavioral or work characteristics are required to BE an awesome teammate at Brown & Brown

• Planning/organizing—the individual prioritizes and plans work activities and uses time efficiently.  Makes good and timely decisions that propels our company forward
• Interpersonal skills—the individual maintains confidentiality, remains open to others' ideas and exhibits willingness to try new things.  Creates an environment where teammates feel connected and energized.
• Written and Oral communication—Communicate a concise message that resonates every time.  The individual speaks clearly and persuasively in positive or negative situations and demonstrates group presentation skills. 
• Problem solving—Create innovative ways for our customers and our company to be successful.  The individual identifies and resolves problems in a timely manner, gathers and analyzes information skillfully and maintains confidentiality. 
• Quality control—the individual demonstrates accuracy and thoroughness and monitors own work to ensure quality.
• Adaptability—the individual adapts to changes in the work environment, manages competing demands and is able to deal with frequent change, delays or unexpected events. 
• Safety and security—the individual observes safety and security procedures and uses equipment and materials properly.

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions.

Required

• Minimum of three to five years’ work experience in healthcare, health insurance fields pharmacy benefit management, with a focus on pharmacy claims processing and pharmacy benefits related activities
• Ability to build and maintain strong, collaborative working relationships with multiple business units across the company
• Strong communication skills (written and verbal)
• Ability to maintain a high level of confidentiality
• Proficient with MS Office Suite

Preferred

• Associate degree or higher
• Direct PBM claims auditing experience within a PBM and/or Health Plan.
• Pharmacy Technician Certification (CPhT) and/or pharmacy work experience

Pay Range

The pay range provided above is made in good faith and based on our lowest and highest annual salary or hourly rate paid for the role and takes into account years of experience required, geography, and/or budget for the role.

Teammate Benefits & Total Well-Being

We go beyond standard benefits, focusing on the total well-being of our teammates, including:

• Health Benefits: Medical/Rx, Dental, Vision, Life Insurance, Disability Insurance  
• Financial Benefits: ESPP; 401k; Student Loan Assistance; Tuition Reimbursement 
• Mental Health & Wellness: Free Mental Health & Enhanced Advocacy Services
• Beyond Benefits: Paid Time Off, Holidays, Preferred Partner Discounts and more. 

Not reflective of all benefits. Enrollment waiting periods or eligibility criteria may apply to certain benefits. Benefit details and offerings may vary for subsidiary entities or in specific geographic locations. 

The Power To Be Yourself  

As an Equal Opportunity Employer, we are committed to fostering an inclusive environment comprised of people from all backgrounds, with a variety of experiences and perspectives, guided by our Diversity, Inclusion & Belonging (DIB) motto, “The Power to Be Yourself”.