XiFin, Inc. · 15 hours ago
Formulary Compliance Manager
Charleston, SC
Full-time
Onsite
Mid, Senior Level
$60K/yr - $90K/yr
4+ years expXiFin, Inc. is a healthcare technology company focused on improving the efficiency of healthcare systems. The Formulary Compliance Manager will oversee formulary management, ensuring compliance with regulations and collaborating with teams to maintain data integrity in medical claims coding.
Enterprise SoftwareHealth CareHealth DiagnosticsInformation TechnologyMedical DeviceSoftware
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
Qualification
Required
An Associate or Bachelor's degree in a discipline that can be applied to medical claims coding is preferred
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
Detail-driven, accountable leader who brings a strong sense of ownership and rigor to complex regulatory and coding environments, ensuring accuracy, compliance, and trust in mission-critical data
Collaborative partner and trusted advisor who works seamlessly across product, clinical, IT, and external vendor teams to align formulary logic, systems, and operational needs
Proactive problem-solver with the ability to interpret evolving payer policies, anticipate downstream impacts, and drive thoughtful, compliant solutions in dynamic healthcare environments
Customer- and quality-focused subject matter expert who communicates clearly, resolves issues with confidence, and champions continuous improvement to support reliable claims processing and stakeholder success
Preferred
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
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!
Company
XiFin, Inc.
XiFin is a healthcare information technology company that empowers healthcare organizations to navigate an increasingly complex and evolving healthcare landscape.
1001-5000 employees
Funding
Current Stage
Late StageTotal Funding
$8MKey Investors
Goldman SachsWindward Ventures
2025-09-03Series Unknown
2014-07-30Acquired
2006-09-11Series D· $2M
Leadership Team
Erik Sallee
EVP and Chief Financial Officer
Jeff Carmichael
Senior Vice President Of Engineering
Recent News
Company data provided by crunchbase