What's Happening?
RSM is currently seeking a remote Market Conduct Examiner specializing in Health and Pharmacy Benefit Management (PBM) for its Risk & Regulatory Consulting, LLC affiliate. This position is open to candidates across any U.S. location and involves performing
reviews of major insurance companies' operations to verify compliance with state insurance statutes and regulations. The examiner will conduct comprehensive, targeted, and risk-focused market conduct examinations on behalf of state insurance departments. Key responsibilities include reviewing and assessing insurance company documentation and data, drafting organized examination work papers for supervisory review, and assisting with the preparation of reports detailing compliance and recommending solutions. The role also requires knowledge of insurance laws, rules, and regulations, and the ability to analyze new or revised laws to determine their impact. Specific areas of focus include 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. Candidates must have a minimum of 5+ years of insurance experience with a state or federal agency, insurance company, examination firm, or public accounting firm.
Why It's Important?
This remote position for a Market Conduct Examiner is highly significant for the U.S. healthcare and insurance industries. The role directly addresses the critical need for regulatory oversight and compliance within the complex health and PBM sectors. By ensuring insurance companies and PBMs adhere to state statutes and regulations, the examiner helps protect consumers, maintain fair market practices, and uphold the integrity of the U.S. healthcare system. The focus on areas like pharmacy audits, spread pricing, and claims processing highlights the ongoing challenges and scrutiny faced by PBMs, which play a substantial role in drug pricing and access. This position contributes to greater transparency and accountability, potentially leading to better patient outcomes and more equitable healthcare costs. The remote nature of the role also allows RSM to access a broader pool of specialized talent across the U.S., enhancing its capacity to serve various state insurance departments effectively.
What's Next?
RSM will continue to evaluate applicants for the remote Market Conduct Examiner position, with successful candidates integrating into Risk & Regulatory Consulting, LLC. The firm's ongoing commitment to regulatory compliance in the health and PBM sectors suggests a sustained demand for such specialized expertise. As healthcare regulations evolve and the PBM landscape continues to face scrutiny, the role of market conduct examiners will remain crucial. This could lead to further expansion of RSM's regulatory consulting services and potentially influence policy discussions around PBM practices and insurance oversight. The remote work model for this role may also serve as a blueprint for other regulatory and compliance functions within the professional services industry, demonstrating the feasibility of distributed teams for critical oversight activities.
Beyond the Headlines
The Market Conduct Examiner role in the health and PBM sector delves into the intricate ethical and economic dimensions of the U.S. healthcare system. The scrutiny of PBM practices, such as spread pricing and pharmacy reimbursement, touches upon fundamental questions of fairness, transparency, and the equitable distribution of healthcare costs. This position is at the forefront of ensuring that the financial mechanisms of healthcare do not unduly burden patients or smaller pharmacies. The regulatory oversight provided by such examiners can trigger broader policy debates and legislative actions aimed at reforming PBM operations and strengthening consumer protections. Furthermore, the role highlights the constant tension between market efficiency and regulatory control in a sector as vital as healthcare, underscoring the need for vigilant monitoring to prevent anti-competitive practices and ensure public trust. The remote nature of the job also emphasizes the increasing reliance on digital tools and secure communication for sensitive regulatory work.
