XTN-0600829 | PHARMACY CLAIMS AUDITOR

The Pharmacy Claims Auditor is responsible for conducting pharmacy network audits to ensure compliance with government regulations and decrease fraud. The position documents and makes adjustments to pharmacy claims as determined by audit findings to ensure the integrity and accuracy of MedImpact’s claims data.

This position requires technically complex analysis and a high degree of accuracy, carrying with it high consequence of error for MedImpact and its customers. It relies upon business knowledge, including industry concepts and practices, technical skills, and prior experience to plan and accomplish goals.

• 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

• Prepares and completes desk and on-site audits, including obtaining claim data for selection analysis, reviewing dispensing activities for billing errors, reviewing federal/state/local pharmacy laws, documenting audit results, notifying pharmacies, and preparing travel 
  itineraries, audit plans, & schedules as appropriate;
• 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 which includes, but not limited to: (1) Making outbound calls to pharmacies verifying claim accuracy and support billing adjustments, and (2) Following-up with pharmacies by faxing and emailing related documents.
• Analyzes pharmacy profile reports for possible claim discrepancies, and fraud, waste, and abuse.
• Prepares prescription listings for desk and on-site audits as appropriate.
• Performs extensive follow-up inspection of claims data based on extrapolations from initial audit results.
• Prepares correspondence to pharmacy providers, requesting documentation to validate detected claim discrepancies.
• Reviews documentation and makes appropriate claim adjustments according to audit findings.
• Prepares audit outcome documentation for pharmacies.
• Documents results and that appropriate client invoicing is completed for services.
• Adheres to unit guidelines for escalation of issues, including provider non-compliance.
• Follows unit protocol for notifying management of potential fraud, waste, and abuse. 
• Ensures that critical issues related to pharmacy 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.

• Bachelor’s degree required along with 3 years’ pharmacy experience (or equivalent combination of education and experience). 
• Pharmacy License.
• Experience in Long Term Care, Specialty or Mail Order pharmacy will be considered. Claim audit experience is a plus.
• 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.
• Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.
• Ability to write reports, business correspondence, and procedure manuals.
• Ability to effectively present information and respond to questions from groups of managers, clients, customers, and vendors.
• Knowledge of medications and standard dosages.
• Strong knowledge of the practice of pharmacy, including statutory laws, regulations, and methods of filling and filing prescriptions.