Bluespine-Pharmacy Claims Audit Lead (Part-Time Role)

Description

Bluespine is an innovative new startup on a mission to transform healthcare spending for self-insured employers. By employing cutting-edge technologies, we identify overbilling in paid medical and pharma claims, which causes billions of dollars in losses across the entire industry. Bluespine can offer personalized precision by validating claims at scale against employer’s unique plans, policies, and contracts, ensuring unparalleled accuracy.

We are looking for a passionate individual to lead and shape the prescription drug claim audits practice on a part-time basis, with the option to increase the role in the future, and support engineering and data science teams as a subject matter expert as we grow and improve our technology.

Responsibilities

• Lead and conduct prescription drug claim audits to ensure accuracy and compliance with contractual obligations, regulatory standards, and formulary terms. This includes the entire audit cycle from scope definition to final report and presenting the findings. 
• Review customers’ PBM contracts and plan documents and identify what can be tested and how. Validate algorithmic results and provide feedback to help tune them.
• Utilize data analysis techniques and company’s systems to develop and validate new concepts, and identify potential instances of fraud, waste, and abuse.
• Support engineering and data science teams with prescription drug claim audit concepts, data mapping, and defining data requirements.

Requirements

• Extensive knowledge of pharmacy benefits, prescription drugs, claim adjudication, PBM contracts.
• 3+ years’ experience conducting pharmacy audits for commercial PBM plans.
• Familiarity and ability to work with relevant external data sources such as Medi-span, FDA’s Orange Book, etc.
• Hands-on experience in analyzing claims data using SQL / Excel / Python, or similar.
• Strong analytical skills and ability to approach tasks in a scientific manner.
• Independent, Organized, and with excellent communication skills.

Advantages

• Medical/clinical background.
• Experience working with engineering/data science teams.
• Previous work for PBM.