Pharmacy Claims Auditor

innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. 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!

Responsible forconducting 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
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. 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.
This is an internal and external client facing position that requires excellent customer service skills and interpersonal communication skills (listening/verbal/written). Respond to requests for service and assistance from clients; Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
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. 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.).
Strong knowledge of the practice of pharmacy, including applicable federal and state laws, regulatory requirements, prescription dispensing processes, and documentation standards.
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.
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.
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 respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community.
Decision Quality
Customer Focus
Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
This position may regularly be exposed to or encounter moving mechanical parts, high, precarious places, fumes or airborne particles, toxic or caustic chemicals, outdoor weather conditions, risk of electrical shock or vibration. The noise level in the work environment is usually moderate (examples: business office with computers and printers, light traffic).
This position works on-site at the San Diego Headquarters or other company location (or from a remote location with management approval based on business requirements). This is a full-time non-exempt position requiring one to be able to work overtime from time to time in order to get the job done. Therefore, one must have the ability to work nights, weekends or on holidays as required. The typical working hours for this position are Monday through Friday from 8:00am to 5:00pm.
Travel
This position requires domestic travel of up to 10% of the time.
Medical / Dental / Vision / Wellness Programs
~ Paid Time Off / Company Paid Holidays
~ Life and Disability Insurance
~ Tuition Reimbursement
~ Employee Referral Bonus

MedImpact, is a privately-held pharmacy benefit manager (PBM) headquartered in San Diego, California. Equal Opportunity Employer, Male/Female/Disabilities/Veterans
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.