Pharmacy Network Auditor
About The Position
We are a healthcare technology company that provides platforms and solutions to improve the management and access of cost-effective pharmacy benefits. Our technology helps enterprise and partnership clients simplify their businesses and helps consumers save on prescriptions. As a leader in SaaS technology for healthcare, we offer innovative solutions with integrated intelligence on a single enterprise platform that connects the pharmacy ecosystem. With our expertise and modern, modular platform, our partners use real-time data to transform their business performance and optimize their innovative models in the marketplace.
Requirements
- Previous Pharmacy Audit Experience is required, understanding of the processes and industry related guidelines are mandatory
- 5+ years of experience in a Retail Pharmacy setting and/or Pharmacy Benefits Management organization
- Strong understanding of the pharmacy claims processing ecosystem
- Strong understanding of pharmacy relationships and NCPDP data extracts
- Proficient knowledge and ability to leverage current reporting tools to identify audit and FWA issues proactively
- Strong understanding of Pharmacy Network Standards and how to manage potential FWA issues via claims data
- Proficient knowledge of URAC and CMS network requirements in addition to Federal and State level auditing network requirements
- Ability to research, analyze and report on audit results and industry trends in FWA
- Proven ability to work independently and drive results
- Detail-oriented, ability to multitask, proactive thinker
- Excellent written and verbal communication skills
- Experience with presenting and or training
- Proficiency in MS Word and Excel
Responsibilities
- Pharmacy Network Auditor evaluates, reports and monitors all aspects pertaining to Pharmacy Network Auditing services
- The role will also serve as a subject matter expert within the Company regarding standard monitoring measures, auditing procedures, and best practices
- Assess the risks outlined by audit vendor, perform appropriate audit procedures, and collaborate with pharmacy management to resolve issues in a timely and efficient manner
- Draft and communicate audit findings and observations to internal stakeholders such as Finance and Client Success; Provide Quarterly Network Audit Performance Reports to the leadership to monitor Audit Program efficacy
- Screen and summarize authorized vendor audit results in detail prior to initiating claim adjustments
- Review results to determine details of fraudulent, erroneous, or abusive billing activity
- Responsible for leveraging current BI Tools to analyze claims data for potential investigational FWA breaches of network pharmacies
- Maintain audit documentation, and prepare statistical data for internal stakeholder review and action
- Develops and updates Standard Operating Procedures (SOPs) for audit and FWA Programs
- Collaborates with key stakeholders to support pharmacy network initiatives
- Establish and maintain relationships with Implementations, Client Services, Benefit Administration, UAT/QA, IT, Product, Finance, Clinical Departments with focus on actively engaging the appropriate teams to enhance the Audit/FWA program
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
