Market Conduct Examiner; Health and PBM

Market Conduct Examiner (Health and PBM) page is loaded## Market Conduct Examiner (Health and PBM) locations:
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JR118713

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** Market Conduct Examiner (Health and PBM)
**** Risk & Regulatory Consulting, LLC****(Regulatory Insurance)
**** Work from home-any US location
**** Position Overview
** The Market Conduct Examiner will be responsible for performing reviews of major insurance companies’ operations, marketing, underwriting, mental health parity quantitative and non-quantitative treatment limits, pharmacy benefit management practices, rating, policyholder service, producer licensing, complaint handling and claims handling processes to verify compliance with states’ insurance statutes and regulations.
** Specific Duties and Responsibilities*****(Responsibilities may vary slightly depending on seniority level)
**** Perform comprehensive, targeted and risk focused market conduct examinations to determine compliance with states’ insurance statutes and regulations on behalf of state insurance departments.
* Review and assess insurance company’s documentation and data to determine compliance with states’ insurance statutes and regulations.
* Draft examination work papers in an organized manner for supervisory review.
* Assist with the preparation of reports, exhibits, and other supporting documentation and schedules that detail a company’s compliance with insurance statutes and regulations and recommend solutions.
* Submit draft examination reports and other deliverables for supervisory review.
* Recommend/document actions to ensure compliance with insurance statutes and regulations.
* Must possess knowledge of and provide guidance of insurance laws, rules, and regulations.
* Review and analyze new, proposed, or revised laws, regulations, policies, and procedures in order to determine compliance with states’ insurance statutes and regulations and interpret their meaning and determine impact to the insurance company.
* Analyze reports and records relating to specific and overall operations of insurance companies; prepare clear, complete, concise, and informative compliance reports of condition of insurance companies for supervisory review.
* Consistently enhance knowledge of principles, practices, techniques, and methods of insurance examination and regulations; insurance laws and Insurance Commissioner’s rulings; and related Attorney General Opinions and court decisions; insurance company practices; statistical sampling procedures; basic mathematics.  + This includes, but is not limited to, analyzing compliance pertaining to review of pharmacy audits conducted by PBMs, spread pricing, pharmacy reimbursement, dispensing fee requirements, annual reports, contract review, financial review, internal and external appeals, claims processing, and network adequacy.
* Complete examination work in the required state software platform.  + This includes utilizing Team Mate+ and other software platforms as required.
* Ensure all deadlines presented by examination workplan schedule and PBM management are met.  + This includes, but is not limited to, ensuring all audit deliverables are met timely and accurately, including assisting in client and examinee company point(s) of contact relationships.
* Ability to adapt to a fast-paced environment.
** Requirements
* ** Bachelor’s Degree in Business, Risk Management, Accounting or Finance; MBA and/or professional certification/s preferred
* Minimum of 5+ years insurance experience with a State or Federal agency, insurance company, examination firm or with a public accounting firm as an internal or external auditor, adjuster,…