Manager, Pharmacy Audit

MedImpact Healthcare Systems, Inc.•San Diego, CA

11d•$81,581 - $138,690•Onsite

About The Position

MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team! Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare. At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution!

Requirements

BS/BA degree or equivalent plus 5+ years of experience
1 year of SME in respective area(s)
3+ years of supervisory experience
4 years of MedImpact experience plus an appropriate external leadership training program and internal mentorship with a seasoned leader (Dir+) that must completed within 12 months in new position may substitute for the supervisory experience requirement.
Strong proficiency with personal computers and MS Office products to include a good working knowledge of MS Word, Excel, Access and Outlook.
Familiarity with relational database systems.
Knowledge of SQL software front ends such as Med Optimize highly desirable.
Active Pharmacy Technician or pharmacist licensure in any one of the 50 United States is preferred.
Ability to obtain and maintain a valid driver’s license and car insurance
Prior pharmacy benefit management experience preferred.
Ability to read and interpret prescriptions.
Knowledge of medications and usual dosages.
Excellent knowledge of the practice of pharmacy, including statutory laws, regulations, and methods of filling and filing prescriptions.
Ability to define problems, collect data, establish facts, and draw valid conclusions.
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
Ability to make effective and persuasive speeches and presentations on controversial or complex topics to top management, public groups, and/or boards of directors.
Ability to write speeches and articles using original or innovative techniques or style.

Nice To Haves

Knowledge of SQL software front ends such as Med Optimize highly desirable.
Active Pharmacy Technician or pharmacist licensure in any one of the 50 United States is preferred.
Prior pharmacy benefit management experience preferred.

Responsibilities

Develops and implements premium strategy and services to meet organizational and client audit, FWA needs.
Manages Pharmacy Audit and FWA operations to ensure effective service delivery to all stakeholders including clients, Account Service, other departments, etc.
Designs audit and FWA programs to reduce unnecessary drug costs, recoup monies and provide cost savings for MedImpact clients.
Establishes standards and procedures for the quality and timeliness of work to ensure accuracy in identifying exposures and documenting potential risk areas for MedImpact and/or clients
Establishes procedures to ensure compliance with federal regulations and Company network agreements. Ensure auditors understand NABP and state specific pharmacy laws impacting claims review prior to audits.
Develops and conducts training for audit staff. Ensures continuing education involving department process changes or laws affecting pharmacy audits.
Ensured all audit contractual obligations are completed in a timely manner and meet MedImpact’s highest expectations.
Recruits, manages and retains the necessary resources to successfully perform the duties for the Provider Auditing group.
Provides day-to-day management of department, including developing and administering policies, business processes and quality standards, and developing and managing a department budget.
Ensures that deliverables are on time, within budget, and meet the quality levels expected by internal and external customers.
Manages the overall planning, coordination of schedules and completion of desk audits and on-site audits.
Ensures summary and follow-up reports outlining audit findings and detail listing of discrepancies identified during the audit process are reported to the Director, Pharmacy Compliance, FWA via the Report of Findings approved template.
Documents, monitors, and follow-ups on all client speciifc audit, FWA requests, research and analysis.
Assists in the implementation of a tracking system for audit claims, FWA as a measure of department performance.
Develops and maintains reporting tools for the department, Pharmacy Adjudication Committee (CAC), law enforcement and clients.
Responsible for intervening and resolving issues, problems, and/or concerns from clients, and informing senior management regarding client issues that may have an adverse impact.
Provides leadership coverage, operational oversight, and management support for Pharmacy Compliance and FWA functions during periods of organizational change, staffing transitions, leave coverage, special projects, or increased business demand.
Serves as a cross-functional leader within the Pharmacy Compliance and FWA organization, providing operational support, project leadership, subject matter expertise, and management coverage across multiple functional areas as business priorities require.
Participates in initiatives involving audit, investigations, credentialing, analytics, compliance operations, reporting, and other departmental functions to ensure effective service delivery, operational continuity, and organizational flexibility.
Provides leadership support and subject matter expertise for pharmacy credentialing and recredentialing activities, assisting with regulatory compliance, accreditation requirements, audits, and special projects as business needs require.
Supports fraud, waste, abuse, and compliance investigations through data analysis, audit activities, case reviews, and collaboration with internal stakeholders and regulatory agencies, as appropriate.
Leverages reporting, analytics, and operational data to identify trends, risks, anomalies, and opportunities for process improvement across Pharmacy Compliance and FWA programs. Develops and maintains management reporting and performance metrics to support business decisions.
Partners with business, operational, and technology teams to support the development, implementation, testing, and enhancement of Pharmacy Compliance and FWA-related programs, workflows, controls, and system capabilities.
Supports client implementations, regulatory examinations, accreditation reviews, client audits, and requests for information by providing subject matter expertise and operational guidance.
Leads or participates in strategic initiatives designed to improve operational efficiency, regulatory compliance, quality outcomes, service delivery, and organizational performance.
Identifies opportunities to enhance department effectiveness through process improvement, technology adoption, automation, reporting enhancements, and data-driven decision making.
Supports leadership development, staff mentoring, cross-training initiatives, and succession planning efforts to enhance organizational capability and business continuity.
Manages assigned staff in the segment area. Responsible for the overall direction, coordination, and evaluation of the unit. Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems. Supports and enforces all company policies and procedures in a fair and consistent manner, taking corrective action whenever necessary.
This is an internal and external client facing position that requires excellent customer service skills and interpersonal communication skills (listening/verbal/written). One must be able to; manage difficult or emotional client situations; Respond promptly to client needs; Solicit client feedback to improve service; Respond to requests for service and assistance from clients; Meet commitments to clients.