Program Integrity Auditor

Avera•Sioux Falls, SD

23h•$23 - $33•Onsite

About The Position

Responsible for reviewing retail prescriptions that qualified for the hospital's 340B Drug Pricing Contract Pharmacy Program. This role is required to review all eligible prescriptions and check eligibility against the hospital's electronic medical record for appropriate matching documentation and make corrections within the pharmacy's reprocessing window and provide regular feedback to the leadership of Pharmacy Business & Analytics on auditing trends.

Requirements

The individual must be able to work the hours specified.
To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds.
Associate's or certified pharmacy technician.
or Certified Pharmacy Technician (CPhT) - Pharmacy Technician Certification Board (PTCB) Certified as a pharmacy technician by the Pharmacy Technician Certification Board (PTCB) Upon Hire
1-3 years experience within a hospital business office, medical related field, health plan, third party administrator, or managed care industry

Responsibilities

Review, analyze and determine eligibility of contract pharmacy claims by investigating patient records in hospital EMR to ensure each prescription meets the 340B patient definition.
Reverse ineligible claims within pharmacy reprocessing window.
Communicate audit results with the Pharmacy Business & Analytics Team, External 340B Software Vendor, Contract Pharmacies, Avera 340B Steering Committee and Avera Corporate Compliance Committee.
Document all requested reversals and ensure reversals occur
Maintain accurate provider file for hospital's assigned to.
Remain current with 340B patient definition and current federal auditing guidelines and best practices.
Monitor and report trending of third party contract pharmacy audits to Director of Pharmacy Business & Analytics, Avera 340B Steering Committee and Avera Corporate Compliance Committee.