XTN-E387320 | PHARMACY AUDIT SUPPORT REPRESENTATIVE

The Pharmacy Audit Support Representative is responsible for analyzing and monitoring pharmacy claims to ensure compliance with Pharmacy rules and regulations along with state and federal guidelines. Communicate with network pharmacies to verify and/or request adjustments to pharmacy claims as determined by audit support findings to ensure the integrity and accuracy of MedImpact’s claims data.

• Health Insurance/HMO 
• Enjoy unlimited MadMax Coffee
• Diverse learning & growth opportunities
• Accessible Cloud HR platform (Sprout)
• Above standard leaves
• Quarerly incentive payouts based on performance

• Reviews and analyzes claims data against pharmacy policy/procedures and knowledge of  prescription medications to determine details of fraudulent or incorrect billing activity.
• Uses MIDAS Claims Software as well as MedImpact internally-developed systems and reports to accomplish work deliverables.
• Communicates with pharmacies to ensure proper billing activity, claims data verification and request claim adjustments as needed. 
• Performs and finalizes audit support findings including obtaining claim data for verification and accuracy. Reviews dispensing activities for billing errors; reviews federal/state/local pharmacy laws, documents audit support results, and notifies pharmacies as needed.
• Documents all telephone conversations and keeps record of faxes with pharmacies and Corporate Contacts for Chain Pharmacies.
• Prepares correspondence to pharmacy providers, requesting documentation to validate potential claim discrepancies. 
• Reviews documentation and makes appropriate claim adjustments according to audit support findings. 
• Adheres to the department’s guidelines for escalation of issues, including provider non-compliance.
• Follows department’s protocol for notifying management of potential fraud, waste, and abuse.
• Ensures critical issues related to pharmacy credentialing and continuing network participation are recognized, documented, and addressed.
• Performs report preparation, participation in special projects, problem resolution and other activities that support the “Provider Audit” process.

• Bachelor’s Degree in Pharmacy or any other related courses.
• 2 years experience similar to the role.
• Prior administrative experience or CSA is preferred.
• Ability to solve practical problems and deal with a variety of variables in situations where only limited standardization exists.
• Ability to interpret instructions furnished in written, oral, diagram, or schedule form.
• Strong knowledge of the practice of pharmacy, including statutory laws, regulations, and methods of filling and filing prescriptions.
• Ability to work independently with minimal direction and strong decision-making ability. 
• Strong organizational and follow-through skills. 
• Strong interpersonal, oral, and written communication skills with the ability to maintain tact and diplomacy in difficult situations.

Competencies

• To perform the job successfully, an individual should demonstrate the following competencies:
  • Adaptability - Adjusts quickly to evolving situations by integrating new information, remaining flexible, recognizing and implementing necessary changes and taking advantage of opportunities presented by new developments.
  • Communication - Expresses self clearly and effectively in face-to-face interactions, presentations and written documents, and employs active listening skills to ensure productive interactions.
  • Customer and Quality Focus - Actively demonstrates a personal concern for understanding client needs, ensuring the quality of products and services, maintains a high level of customer satisfaction, and contributes to continuous improvement of products and processes.
  • Productivity - Achieves high-quality, concrete results, completing tasks quickly and responding to problems as they arise in order to ensure that deadlines and production goals are met.
  • Professionalism - Acts with integrity, shows self to be reliable and responsible, displays emotional intelligence, and conscientiously complies with all relevant laws, policies, and procedures.
  • Quantitative Skills - Competently uses quantitative abilities appropriate for the job, such as basic math skills, interpretation of spreadsheets, or use of charts, graphs and statistics.

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 accommodations 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 frequently required to use hands to finger, handle, or feel and reach with hands and arms. The employee is occasionally required to stand; walk and stoop, kneel, crouch, or crawl. 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.