Formulary Compliance Manager - Charleston, SC, US

Are you interested in harnessing technology and AI to transform healthcare? ·  At XiFin, we believe a healthier, more efficient healthcare system starts with strong financial and operational foundations. Our innovative technologies help diagnostic providers, laboratories, and hea ...

Job description

Are you interested in harnessing technology and AI to transform healthcare?

 At XiFin, we believe a healthier, more efficient healthcare system starts with strong financial and operational foundations. Our innovative technologies help diagnostic providers, laboratories, and healthcare systems manage complexity, drive better outcomes, and stay focused on what matters most: patient care.

We're on a mission to simplify the business side of healthcare—and we know that mission takes people from all backgrounds and experiences. Whether you're early in your career or bringing years of expertise, we welcome your perspective, your curiosity, and your passion. We value individuals who ask questions, challenge the status quo, and want to grow while making a real difference.

About the Role

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. 

How you will make an impact:

In this role, you'll:

• 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.

What you will bring to the team:   

We're looking for someone with a growth mindset and a passion for learning. You might be a great fit if you:

• 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.

Skills and experience you have: 

You don't need to check every box. We will consider a combination of education and experience, including: 

• 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

Preferred Skills & Certifications

• 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

Why XiFin?

We're more than just a healthcare technology company—we're a team that cares about people.
 Here's a glimpse at what we offer:

• 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 

Pay Transparency

At XiFin, we believe in pay transparency and fairness. The expected annual salary range for this role is $60,000 - $90,000. Depending on qualifications, candidates may be considered for an Analyst, Sr. Analyst, or Manager title. 

Final compensation will be determined during the selection process and may vary based on experience, skills, and geographic location.

Accessibility & Accommodations

We're committed to providing an inclusive and accessible experience for all applicants. If you need a reasonable accommodation during the application process, please contact us at

Equal Opportunity Employer

XiFin is proud to be an equal opportunity employer. We value diverse voices and do not discriminate on the basis of race, color, religion, national origin, gender, gender identity, sexual orientation, disability, age, veteran status or any other basis protected by law.

Ready to apply?
We'd love to hear from you—even if you're not sure you meet every qualification. If you're excited about the role and believe you can contribute to our team, please apply. Let's build something meaningful together.