Formulary Compliance Manager
About The Position
The Medical Benefit Formulary & Coding Compliance role serves as the most experienced contributor for the formulary function, providing expert knowledge, strategic oversight, and hands-on execution across all aspects of medical benefit formulary management. The role is responsible for overseeing the accurate implementation and maintenance of formulary data for drugs covered under a medical benefit, DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics & Supplies), immunizations, vaccinations, and clinical testing services. This role ensures compliance with CMS guidelines, Medicare Part B policies, state Medicaid rules, and commercial payer requirements, while serving as a subject matter expert in medical claim coding (HCPCS, CPT, NDC) for pharmacy customers. The position involves close collaboration with internal teams and external vendors to maintain data integrity, support claims processing, and align formulary logic with system and regulatory standards. This role is not pharmacy benefit management (PBM). This is an onsite position located at one of our offices in Dallas, Texas or Charleston, South Carolina.
Requirements
- An Associate or Bachelor’s degree in a discipline that can be applied to medical claims coding is preferred. The successful candidate’s background and training incorporates the appropriate amount of professional skepticism (e.g., auditor, finance, compliance, certified coder) to be successful in the position’s responsibilities.
- Minimum 4 years of experience in medical claim billing with an emphasize on coding of NDCs to the appropriate HCPCS/CPT, including calculation of billed quantities.
- Experience with claims adjudication systems, reimbursement operations, and medical coding.
- Strong understanding of coding systems (HCPCS, CPT, NDC, ICD-10), formulary logic, and DMEPOS structure.
- Experience and knowledge of PDAC, DMEPOS fee schedules, pricing files, and CMS drug pricing tables
Nice To Haves
- Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or Certified Medical Reimbursement Specialist (CMRS)
- Advanced proficiency in Microsoft Excel, including pivot tables, VLOOKUP, and data reconciliation
- Knowledge of PDAC, DMEPOS fee schedules, pricing files, and CMS drug pricing tables
- High attention to detail and ability to identify discrepancies in large data sets
- Excellent communication and cross-functional collaboration skills
Responsibilities
- Oversee the review, implementation, and ongoing maintenance of formulary data for DMEPOS, drugs covered under a medical benefit, immunizations, vaccinations, and clinical test-and-treat services. This role is not pharmacy benefit management (PBM).
- Ensure completeness, accuracy, and regulatory compliance of formulary files to support claims processing in our internal platforms.
- Lead the coordination and execution of formulary coding additions, deletions, and updates in accordance with Medicare Part B policies, NCDs, LCDs, state Medicaid guidelines, and commercial payer policies.
- Perform and institute periodic quality control, conversion factors, pricing, and code validation checks to ensure data accuracy, correct application of modifiers, and consistency in conversion calculations.
- Collaborate closely with internal product, clinical, and IT teams to align formulary logic and rules with operational and system requirements.
- Serve as the primary SME for coding of pharmacy claims processed by XiFin on behalf of our pharmacy clients, including HCPCS, CPT, NDC, conversion calculations, and modifier logic.
- Monitor and interpret federal and state payer policy updates to oversee or recommend necessary system changes (e.g., fee schedules, coverage criteria, code replacements).
- Partner with third-party vendors on the ongoing review of formulary changes, code updates, and file enhancements, ensuring synchronization and version control.
- Respond to and resolve formulary-related inquiries from internal and external stakeholders.
- Ensure compliance with relevant regulations, CMS guidelines, coding standards, and industry best practices.
- Analyze formulary utilization data and trends, and prepare reports to inform leadership.
Benefits
- Comprehensive health benefits including medical, dental, vision, and telehealth
- 401(k) with company match and personalized financial coaching to support your financial future
- Health Savings Account (HSA) with company contributions
- Wellness incentives that reward your preventative healthcare activities
- Tuition assistance to support your education and growth
- Flexible time off and company-paid holidays
- Social and fun events to build community at our locations!
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
