PBM Compliance Manager (Claims Audit) 

Location: This role requires associates to be in-office 1 - 2  days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office.
 

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The PBM Compliance Manager (Claims Audit) is responsible for coordinating pharmacy compliance activities and initiatives across the PBM and the enterprise by maintaining department approved regulatory and legislative compliance plan and implementing effective internal controls.

How You Will Make An Impact:

• Interpret and manage audit requirements (i.e., timelines, internal/external meetings, deliverables, etc.).
• Identifies, monitors, revises and tracks business unit processes and implementing procedures to ensure compliance with all related measures. Identifies potential risks associated with PBM activities and ensures procedures are in place to minimize risks.
• Partners with business units to ensure compliance with all statutory and regulatory requirements.
• Participates as compliance subject matter expert on all mandated projects; achieves business operational compliance with all related measures relative to HIPAA and SOX and Privacy and Security Office initiatives.
• Conducts, directs, leads and facilitates all activities related to Internal and External (Regulatory and Client) audits and responds to findings.
• Analyze auditor results and findings.
• Responsible for client implementation testing.
• Maintain vendor relationships.
• Performs high level regulatory research, develops strategic plans and pro-actively anticipates business needs and requirements.
• Develops and implements training and communication plans; manages and leads scheduled and ad-hoc compliance projects; provides and delivers compliance consultation services to the business unit.

Minimum Requirements:

Requires a BA/BS and minimum of 6 years experience; or any combination of education and experience, which would provide an equivalent background.  

Preferred Skills, Capabilities & Experiences:

• MS/MBA or field related professional designation preferred.
• Travels to worksite and other locations as necessary.
• Experience with pharmacy claims is preferred.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.