Pharmacy Network Auditor

RxSense•Boston, MA

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

Evaluates, reports and monitors all aspects pertaining to Pharmacy Network Auditing services.
Serves as a subject matter expert within the Company regarding standard monitoring measures, auditing procedures, and best practices.
Assesses the risks outlined by audit vendor, performs appropriate audit procedures, and collaborates with pharmacy management to resolve issues in a timely and efficient manner.
Drafts and communicates audit findings and observations to internal stakeholders such as Finance and Client Success.
Provides Quarterly Network Audit Performance Reports to the leadership to monitor Audit Program efficacy.
Screens and summarizes authorized vendor audit results in detail prior to initiating claim adjustments.
Reviews results to determine details of fraudulent, erroneous, or abusive billing activity.
Leverages current BI Tools to analyze claims data for potential investigational FWA breaches of network pharmacies.
Maintains audit documentation, and prepares 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.
Establishes and maintains 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.