Pharmacy Audit Data Analyst

Summary

Milliman is an independent professional services firm delivering solutions across healthcare, risk management, data analytics, and other complex business issues. The Pharmacy Audit Data Analyst will analyze pharmacy claims, guarantees, rebates, and contracts using SQL, develop audit logic and validation checks, and prepare client-ready reports to support dispute resolution and audit improvements.

Responsibilities

• Perform audit testing of pharmacy claims data against contract terms, including discount and dispensing fee pricing guarantees, administrative fees, and other contractual financial guarantees
• Write, troubleshoot, and optimize SQL queries in SQL Server Management Studio (SSMS) to analyze large pharmacy claims data sets
• Conduct rebate audits, including minimum rebate guarantee reconciliations, pass-through rebate testing, and rebate credit reviews
• Translate client and PBM contracts into audit rules by identifying guarantee terms, exclusions, and reporting requirements subject to testing
• Build and maintain validation checks to confirm data completeness and accuracy before analysis begins
• Design, document, and implement new audit tests as contract terms, regulatory requirements, and industry standards evolve
• Prepare client-ready exhibits and reports that clearly communicate audit findings and financial impact
• Support the resolution process by researching PBM responses and rebuttals and substantiating findings with claim-level detail
• Clearly identify and communicate data limitations and any findings that cannot be validated with available information
• Communicate audit findings and data-driven recommendations directly to clients, PBMs, and internal consultants through clear reports and exhibits at key points in the audit lifecycle
• Respond to ad hoc data requests, including claims data monitoring and one-off data pulls, analyses, or exhibits requested by clients and consultants
• Contribute to process improvements, automation, and the development of internal audit tools and templates

Skills

• Bachelor's degree
• 2-6 years of relevant experience
• Health insurance, Pharmacy benefit design, or PBM industry experience (PBM, health plan, insurance, consulting, or pharmacy operations)
• Working knowledge of pharmacy benefit concepts, including copays/coinsurance, AWP-based pricing, MAC, brand and generic classification, specialty drugs, formulary design, and rebates
• Demonstrated ability to write and troubleshoot SQL queries
• Proficiency in Excel, Word, and PowerPoint, including work with large data sets
• Strong analytical, problem-solving, and documentation skills
• Ability to work independently and prioritize competing demands across multiple engagements
• Ability to explain technical terms, data, and analytic concepts in clear, plain language to non-technical audiences, including clients and vendors
• Exceptional attention to detail and accuracy
• Intellectual curiosity and a willingness to question results
• Effective written and verbal communication skills
• Ownership, accountability, and critical thinking
• Individual(s) must be legally authorized to work in the United States without the need for immigration support or sponsorship from Milliman now or in the future
• Preferably in math, health, science, or business discipline
• Experience with SQL Server Management Studio preferred

Qualifications

Must Haves

• Bachelor's degree
• 2-6 years of relevant experience
• Health insurance, Pharmacy benefit design, or PBM industry experience (PBM, health plan, insurance, consulting, or pharmacy operations)
• Working knowledge of pharmacy benefit concepts, including copays/coinsurance, AWP-based pricing, MAC, brand and generic classification, specialty drugs, formulary design, and rebates
• Demonstrated ability to write and troubleshoot SQL queries
• Proficiency in Excel, Word, and PowerPoint, including work with large data sets
• Strong analytical, problem-solving, and documentation skills
• Ability to work independently and prioritize competing demands across multiple engagements
• Ability to explain technical terms, data, and analytic concepts in clear, plain language to non-technical audiences, including clients and vendors
• Exceptional attention to detail and accuracy
• Intellectual curiosity and a willingness to question results
• Effective written and verbal communication skills
• Ownership, accountability, and critical thinking
• Individual(s) must be legally authorized to work in the United States without the need for immigration support or sponsorship from Milliman now or in the future

Nice to Haves

• preferably in math, health, science, or business discipline
• experience with SQL Server Management Studio preferred

Benefits

• Medical, Dental and Vision – Coverage for employees, dependents, and domestic partners.
• Employee Assistance Program (EAP) – Confidential support for personal and work-related challenges.
• 401(k) Plan – Includes a company matching program and profit-sharing contributions.
• Discretionary Bonus Program – Recognizing employee contributions.
• Flexible Spending Accounts (FSA) – Pre-tax savings for dependent care, transportation, and eligible medical expenses.
• Paid Time Off (PTO) – Begins accruing on the first day of work. Full-time employees accrue 15 days per year, and employees working less than full-time accrue PTO on a prorated basis.
• Holidays – A minimum of 10 paid holidays per year.
• Family Building Benefits – Includes adoption and fertility assistance.
• Paid Parental Leave – 11 weeks of paid leave for employees who meet eligibility criteria.
• Life Insurance & AD&D – 100% of premiums covered by Milliman.
• Short-Term and Long-Term Disability – Fully paid by Milliman.
• This role is based out of the Milliman office in San Diego, CA, but candidates hired into this role may work remotely anywhere in the US or onsite if they prefer.
• Milliman invests in skills training and career development and gives all employees access to a variety of learning and mentoring opportunities.
• Milliman Employee Resource Groups (ERG’s) are employee-led communities that influence policy decisions, develop future leaders, and amplify the voices of their constituents.