Pharmacy Auditor - Payment Integrity Complex and Clinical Audit

Elevance Health•Atlanta, OH

30d•Hybrid

About The Position

Pharmacy Auditor - Payment Integrity Complex and Clinical Audit Location: This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Carelon , a proud member of the Elevance Health family of companies, is a healthcare services organization that takes a whole-health approach to making care more integrated, personalized, and affordable. We put people at the center—connecting physical, behavioral, social, and pharmacy services, along with clinical expertise, research, operations, and advanced technology to help care work better, together. Among us are care providers, engineers, data scientists, and other dedicated professionals determined to recover, eliminate and prevent unnecessary medical-expense spending. The Pharmacy Auditor will be responsible for screening, selecting, and auditing high cost drug (HCD), home infusion therapy (HIT), dialysis, and durable medical equipment (DME) claims to ensure they are billed accurately to the medical benefit. Confirms the services rendered are supported by the appropriate documentation and validates the claim is paid correctly according to the provider’s contract and the payer’s reimbursement policies. How you will make an impact: Specializes in review of professional and facility claims with separate line-level payments for high cost drugs, home infusion therapy, renal claims, and durable medical equipment. Analyzes paid claims data to select claims where overpayments are likely, requests the appropriate records where necessary, and accurately prices claims using the contract or claims payment systems. Draws on advanced injectable drug expertise, mastery of pharmacy domain clinical knowledge, and industry knowledge to substantiate conclusions. Utilizes audit tools, auditing workflow systems, and reference information to generate audit determinations and formulates detailed audit findings letters. Maintains accuracy and quality standards as established by audit management. Identifies potential documentation and coding errors by recognizing aberrant coding and documentation patterns such as inappropriate units, excessive units, inappropriate or missing modifiers, excessive frequency, payments allowed in excess of the contract, payments allowed in excess of the contract, excessive waste, equipment rentals that exceed the units billed. Suggests and develops high quality, high value, concept and or process improvement and efficiency recommendations.

Requirements

Requires BS in Pharmacy and minimum of 5 years of experience in pharmacy, home infusion therapy, dialysis and/or durable medical equipment claim auditing; or any combination of education and experience, which would provide an equivalent background
Requires a registered pharmacist
Current unrestricted Pharmacist license in applicable state(s) required

Nice To Haves

Experience conducting pharmacy audits (e.g., claims, prior authorization, formulary/benefit compliance, FWA, dispensing documentation) and documenting findings, trends, and corrective actions
Managed care experience (health plan/PBM environment) with understanding of pharmacy benefit operations, utilization management, and audit/compliance requirements
Specialty pharmacy experience, including high-cost/complex therapies, limited distribution networks, REMS where applicable, and coordination across providers, payers, and manufacturers

Responsibilities

screening, selecting, and auditing high cost drug (HCD), home infusion therapy (HIT), dialysis, and durable medical equipment (DME) claims to ensure they are billed accurately to the medical benefit
Confirms the services rendered are supported by the appropriate documentation and validates the claim is paid correctly according to the provider’s contract and the payer’s reimbursement policies
Specializes in review of professional and facility claims with separate line-level payments for high cost drugs, home infusion therapy, renal claims, and durable medical equipment
Analyzes paid claims data to select claims where overpayments are likely, requests the appropriate records where necessary, and accurately prices claims using the contract or claims payment systems
Draws on advanced injectable drug expertise, mastery of pharmacy domain clinical knowledge, and industry knowledge to substantiate conclusions
Utilizes audit tools, auditing workflow systems, and reference information to generate audit determinations and formulates detailed audit findings letters
Maintains accuracy and quality standards as established by audit management
Identifies potential documentation and coding errors by recognizing aberrant coding and documentation patterns such as inappropriate units, excessive units, inappropriate or missing modifiers, excessive frequency, payments allowed in excess of the contract, excessive waste, equipment rentals that exceed the units billed
Suggests and develops high quality, high value, concept and or process improvement and efficiency recommendations