Manager, Pharmacy Audit

About the role

MedImpact Healthcare Systems, Inc. is seeking an experienced professional to manage Pharmacy Audit and FWA operations while serving as a cross-functional leadership resource across Pharmacy Compliance and FWA functions.

Responsibilities

• Develops and implements premium strategy and services to meet organizational and client audit, FWA needs.
• Manages Pharmacy Audit and FWA operations to ensure effective service delivery to all stakeholders including clients, Account Service, other departments, etc.
• Designs audit and FWA programs to reduce unnecessary drug costs, recoup monies and provide cost savings for MedImpact clients.
• Establishes standards and procedures for the quality and timeliness of work to ensure accuracy in identifying exposures and documenting potential risk areas for MedImpact and/or clients.
• Ensures compliance with federal regulations and Company network agreements.
• Ensures auditors understand NABP and state specific pharmacy laws impacting claims review prior to audits.
• Develops and conducts training for audit staff.
• Maintains continuing education involving department process changes or laws affecting pharmacy audits.
• Ensures all audit contractual obligations are completed in a timely manner and meet MedImpact’s highest expectations.
• Recruits, manages and retains the necessary resources to successfully perform the duties for the Provider Auditing group.
• Manages the overall planning, coordination of schedules and completion of desk audits and on-site audits.
• Ensures summary and follow-up reports outlining audit findings and detail listing of discrepancies identified during the audit process are reported to the Director, Pharmacy Compliance, FWA via the Report of Findings approved template.
• Documents, monitors, and follows up on all client specific audit, FWA requests, research and analysis.
• Develops and maintains reporting tools for the department, Pharmacy Adjudication Committee (CAC), law enforcement and clients.
• Responsible for intervening and resolving issues, problems, and/or concerns from clients, and informing senior management regarding client issues that may have an adverse impact.
• Provides leadership coverage, operational oversight, and management support for Pharmacy Compliance and FWA functions during periods of organizational change, staffing transitions, leave coverage, special projects, or increased business demand.
• Serves as a cross-functional leader within the Pharmacy Compliance and FWA organization, providing operational support, project leadership, subject matter expertise, and management coverage across multiple functional areas as business priorities require.
• Participates in initiatives involving audit, investigations, credentialing, analytics, compliance operations, reporting, and other departmental functions to ensure effective service delivery, operational continuity, and organizational flexibility.
• Supports fraud, waste, abuse, and compliance investigations through data analysis, audit activities, case reviews, and collaboration with internal stakeholders and regulatory agencies, as appropriate.
• Leverages reporting, analytics, and operational data to identify trends, risks, anomalies, and opportunities for process improvement across Pharmacy Compliance and FWA programs.
• Develops and maintains management reporting and performance metrics to support business decisions.
• Supports business, operational, and technology teams to support the development, implementation, testing, and enhancement of Pharmacy Compliance and FWA-related programs, workflows, controls, and system capabilities.
• Supports client implementations, regulatory examinations, accreditation reviews, client audits, and requests for information by providing subject matter expertise and operational guidance.
• Leads or participates in strategic initiatives designed to improve operational efficiency, regulatory compliance, quality outcomes, service delivery, and organizational performance.
• Identifies opportunities to enhance department effectiveness through process improvement, technology adoption, automation, reporting enhancements, and data-driven decision making.
• Supports leadership development, staff mentoring, cross-training initiatives, and succession planning efforts to enhance organizational capability and business continuity.

Qualifications

• BS/BA degree or equivalent plus 5+ years of experience; 1 year of SME in respective area(s); and 3+ years of supervisory experience; 4 years of MedImpact experience plus an appropriate external leadership training program and internal mentorship with a seasoned leader (Dir+) that must completed within 12 months in new position may substitute for the supervisory experience requirement.
• Strong proficiency with personal computers and MS Office products to include a good working knowledge of MS Word, Excel, Access and Outlook.
• Familiarity with relational database systems. Knowledge of SQL software front ends such as Med Optimize highly desirable.
• Active Pharmacy Technician or pharmacist licensure in any one of the 50 United States is preferred.
• Ability to obtain and maintain a valid driver’s license and car insurance.