Pharmacy Claims Auditor I

MedImpact Healthcare Systems, Inc.•San Diego, CA

5d•$25 - $41•Onsite

About The Position

MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team! MedImpact delivers 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 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.
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.
Composure
Decision Quality
Organizational Agility
Problem Solving
Customer Focus
Drive for Results
Peer Relations
Time Management
Dealing with Ambiguity
Learning on the Fly
Political Savvy

Nice To Haves

Intermediate to advanced skill set in MedAccess & MedOptimize preferred.
Strong aptitude to learn and adapt to new programs.

Responsibilities

Conducting compliance desk or onsite audits of retail, mail order, specialty, compound & long-term care (LTC) network pharmacies.
Verifying pharmacy credentials to ensure compliance with applicable government regulations, contractual requirements and MedImpact standards.
Reviewing, documenting and adjusting pharmacy claims based on audit findings to ensure the integrity and accuracy of the MedImpact’s claims processes by network pharmacies.
Ensuring 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.
Preparing and completing 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.
Analyzing pharmacy profile reports for possible claim discrepancies, fraud, and drug abuse.
Preparing prescription requests for Pre-Pay, desk, and onsite audits as appropriate.
Executing in-depth claims data examinations following preliminary audit findings to identify patterns, validate exceptions, and quantify audit outcomes.
Drafting and distributing provider communications requesting documentation to verify compliance with contractual, regulatory, and billing requirements identified through claim review activities.
Evaluating audit documentation and processes claim adjustments based on validated audit findings and compliance with laws and regulation requirements.
Developing audit outcome reports and supporting correspondence for pharmacies, clearly documenting findings, recoveries, and corrective actions as applicable.
Ensuring results are appropriately documented & communicated to clients, while ensuring accurate and timely invoicing of services completed.
Maintaining audit & credentialing policies & procedures, work instructions, and documentation processes.
Educating stakeholders on requirements and processes.
Adhering to department guidelines for escalation of issues, including provider non-compliance.
Following protocol for notifying management of potential fraud, waste, and abuse.
Ensuring that critical issues related to pharmacy audit, credentialing and continuing network participation are recognized, documented, and addressed according to department guidelines.
Performing report preparation, participation in special projects, problem resolution and other activities that support the provider auditing process.
Managing difficult or emotional client situations.
Responding promptly to client needs.
Soliciting client feedback to improve service.
Responding to requests for service and assistance from clients.
Meeting commitments to clients.