Pharmacy Claims Auditor I

MedImpact•San Diego, CA

2d•Onsite

About The Position

Responsible for conducting compliance desk or onsite audits of retail, mail order, specialty, compound & long-term care (LTC) network pharmacies. Verifies pharmacy credentials to ensure compliance with applicable government regulations, contractual requirements and MedImpact standards. Reviews, documents and adjusts pharmacy claims based on audit findings to ensure the integrity and accuracy of the MedImpact’s claims processes by network pharmacies. Ensures audits are completed in a timely manner and credentialing of participating providers by ensuring that records for each audit are complete and up to date.

Requirements

BS/BA and 2+ years’ experience or equivalent combination of education and experience
Intermediate to advanced skill set in MS Office (Word, Excel, PowerPoint, Project, and Outlook) required.
Familiarity with relational database systems and SQL software front ends such as Business Objects highly desirable.
Intermediate to advanced skill set in MedAccess & MedOptimize preferred.
Strong aptitude to learn and adapt to new programs.
Pharmacy Technician license or national certification (PTCB) required.
Pharmacy and/or pharmacy audit experience required.
Possession of a valid driver’s license and ability to provide a certificate of insurance indicating adequate auto insurance limits (as defined by MedImpact Healthcare Systems, Inc.).
Ability to read and interpret hand-written prescriptions.
Knowledge of medications and standard dosages.
Strong knowledge of the practice of pharmacy, including applicable federal and state laws, regulatory requirements, prescription dispensing processes, and documentation standards.
Self-motivated professional with strong decision-making, organizational, and follow-through skills, capable of working independently with minimal direction
Strong interpersonal and verbal and written communication skills with the ability to effectively navigate challenging situations while maintaining professionalism, tact, and diplomacy.
maintain tact and diplomacy in difficult situations.
Performs highly complex analytical work requiring exceptional attention to detail, accuracy, and independent judgment.
Utilizes business acumen, industry knowledge, and technical expertise to evaluate risks, ensure compliance, and make recommendations that support organizational and client objectives while minimizing operational and financial exposure.
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 write reports, business correspondence, and procedure manuals.
Ability to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community.

Nice To Haves

Familiarity with relational database systems and SQL software front ends such as Business Objects highly desirable.
Intermediate to advanced skill set in MedAccess & MedOptimize preferred.

Responsibilities

Prepares and completes Pre-Pay reviews, desk and/or and onsite audits to evaluate compliance with contractual, regulatory, and pharmacy practice requirements Including obtaining and analyzing claim data, reviewing prescription hardcopy, assessing dispensing and billing practices, reviewing applicable federal, state, and local pharmacy regulations, documenting audit findings, communicating results to pharmacies, and developing audit plans, schedules, and travel arrangements as needed
Analyze pharmacy profile reports for possible claim discrepancies, fraud, and drug abuse
Prepares prescription requests for Pre-Pay, desk, and onsite audits as appropriate
Executes in-depth claims data examinations following preliminary audit findings to identify patterns, validate exceptions, and quantify audit outcomes
Draft and distribute provider communications requesting documentation to verify compliance with contractual, regulatory, and billing requirements identified through claim review activities
Evaluates audit documentation and processes claim adjustments based on validated audit findings and compliance with laws and regulation requirements
Develops audit outcome reports and supporting correspondence for pharmacies, clearly documenting findings, recoveries, and corrective actions as applicable
Ensures results are appropriately documented & communicated to clients, while ensuring accurate and timely invoicing of services completed
Maintains audit & credentialing policies & procedures, work instructions, and documentation processes.
Educates stakeholders on requirements and processes
Adheres to department guidelines for escalation of issues, including provider non-compliance
Follows protocol for notifying management of potential fraud, waste, and abuse.
Ensures that critical issues related to pharmacy audit, credentialing and continuing network participation are recognized, documented, and addressed according to department guidelines
Performs report preparation, participation in special projects, problem resolution and other activities that support the provider auditing process.
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.