CVS Health-posted 3 months ago
$43,888 - $85,068/Yr
Full-time • Entry Level
Phoenix, AZ
5,001-10,000 employees
Ambulatory Health Care Services

This position is an exciting opportunity to join a specialized team of auditors as part of CVS Caremark's extensive Pharmacy Audit division. The Medicare Pharmacy Claims Auditor will administer assigned Medicare Part-D Compliance Audit Programs, review pharmacy submitted Medicare claims, make independent decisions, and call network pharmacies to audit submitted information and communicate business requirements. Candidates will work with other auditors to successfully complete audit projects. Candidates must be highly motivated, possess strong communication skills, effective time-management skills, and be very detail-oriented. Candidates will become an expert on the CVS Health Medicare Audit Programs and will own one or more of those program processes on an ongoing basis. Candidates must possess extremely strong teamwork and collaboration skills and be skilled in sharing common workloads with peers. Candidates will have expansive opportunities to innovate and develop new tools to enhance the execution of audit programs, and work with internal and external partners to develop successful solutions within the scope of the processes for which they are accountable. This helps keep CVS Health plans in compliance with CMS requirements and maintain positive STAR ratings.

  • Telephone outreaches to network pharmacies to verify claim information.
  • Transmission of audit requests to pharmacies.
  • Review of hard copy prescriptions to verify compliance with CMS requirements and CVS Health contractual requirements.
  • Review incoming documentation from pharmacies and input information into internal CVS Health audit systems.
  • Corresponding with network pharmacies to answer questions regarding Medicare Audit Programs.
  • Monitor assigned audit processes and report statuses on a regular basis.
  • Meeting with internal partners to develop and communicate business objectives.
  • 1+ year(s) combined experience in a PBM or pharmacy.
  • 5+ years combined experience in PBM or pharmacy.
  • 2+ years experience in PBM or pharmacy claim processing systems.
  • Familiarity with current CMS Medicare Part-D compliance regulations.
  • Advanced level of technical skillsets including Microsoft Excel, Microsoft Access, and SQL databases.
  • PTCB certification.
  • Affordable medical plan options.
  • 401(k) plan (including matching company contributions).
  • Employee stock purchase plan.
  • No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
  • Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.
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