Responsible for conducting complex reviews of pharmacy claims for daily and desk audits. Responsibilities include collecting/evaluating pharmacy claims, records, and any other health related records for the purpose of identifying areas of fraud, abuse, or waste in the pharmacy program. Ensure all client contract deliverables are met within the audit function. Must be able to work independently.
Reviews and analyzes rules, regulations, and policies governing the covered healthcare services to properly evaluate, audit, substantiate, and identify areas of potential non-compliance.
Conducts pharmacy concurrent bill reviews ensuring claims adhere to State and Federal Contractual requirements.
Conducts desk audits of defined Claims, analyze results, contact pharmacies for claim corrections and recoupment. Track results and documentation.
Conducts independent and complex audits of pharmacy billings to determine compliance with applicable laws, rules, and regulations.
Prepares audit finding documents using established designs and processes that includes clear and concise written explanation of findings referencing appropriate policy citations, developing an itemized report of findings listing the specific claims and errors identified, and including other required attachments that clarify or provides direction in the audit process.
Prepares and submits monthly reports summarizing activities, findings, and recoveries.
Required Skills & Experience:
Knowledge of pharmacy claims
Pharmacy Audit experience
Knowledge of research principles and methods.
Knowledge of the use of data processing/algorithms in conducting research.
Knowledge of basic statistical concepts and methods.
Knowledge and extensive experience with Excel.
Effective Communication Skills, written and verbal.
Highly analytical and detail oriented
Ability to analyze policies and procedures, reach logical conclusions, and make sound recommendations for audit findings.
Certified Pharmacy Technician credentials and having two years of related experience in a retail, hospital, mail order, and/or long-term care pharmacy setting. Associate Degree in Public/Community Health, Health Administration, Business/Public Administration, and (2) years of progressively responsible experience in the planning or reviewing of health programs or services, or preparing and designing health care related reports.
Job Type: Contract
Salary: $25.00 – $27.00 per hour
Monday to Friday
Work Location: One location
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