Pharmacy Claims Auditor I

Exemption Status:United States of America (Non-Exempt)
$25.33 - $33.25 - $41.16
“Pay scale information is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any selected candidate or employee, which is always dependent on actual experience, education, qualifications, and other factors. A full review of our comprehensive pay and benefits will be discussed at the offer stage with the selected candidate.”
This position is not eligible for Sponsorship.
MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team!
Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare.
At MedImpact, we deliver 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!
Job Description
Summary
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
Essential Duties and Responsibilities include the following. Other duties may be assigned.
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.
Supervisory Responsibilities
No supervisory responsibilities
Client Responsibilities
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.
Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
Education and/or Experience
BS/BA and 2+ years’ experience or equivalent combination of education and experience
Computer Skills
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.
Certificates, Licenses, Registrations
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.).
Other Skills and Abilities
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.
Reasoning Ability
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.
Mathematical Skills
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.
Language Skills
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.
Competencies To perform the job successfully, an individual should demonstrate the following competencies:
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
Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this Job, the employee is regularly required to sit and talk or hear. The employee is regularly required to stand; walk; use hands to finger, handle, or feel and reach with hands and arms. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.
Work Environ