Pharmacy Auditor - Payment Integrity Complex and Clinical Audit

About the role

The Pharmacy Auditor will screen, select, and audit high cost drug (HCD), home infusion therapy (HIT), dialysis, and durable medical equipment (DME) claims to ensure accurate billing and proper documentation. Responsibilities include analyzing paid claims data, generating audit determinations, and identifying potential documentation and coding errors.

Responsibilities

• Review professional and facility claims with separate line-level payments for HCD, HIT, renal claims, and DME
• Analyze paid claims data to identify claims where overpayments are likely
• Request appropriate records and accurately price claims using contract or claims payment systems
• Utilize audit tools, auditing workflow systems, and reference information to generate audit determinations and formulate detailed audit findings letters
• Maintain accuracy and quality standards as established by audit management
• Identify and suggest high quality, high value, concept and process improvement recommendations

Requirements

• BS in Pharmacy or equivalent experience
• Minimum of 5 years of experience in pharmacy, home infusion therapy, dialysis, and/or durable medical equipment claim auditing
• Current unrestricted Pharmacist license in applicable state(s)

Preferred Skills, Capabilities And Experiences

• Experience conducting medical/drug audits
• Managed care experience (health plan/payor environment)
• Specialty pharmacy experience, including high-cost/complex therapies, limited distribution networks, and coordination across providers, payers, and manufacturers
• Experience with billing/auditing for Home Infusion, DME, and/or Dialysis

Benefits

Carelon offers a comprehensive benefits package including medical, dental, vision, short and long-term disability, 401(k) +match, stock purchase plan, life insurance, wellness programs, and financial education resources. The company also provides incentives for vaccination against COVID-19 and Influenza.

Pay

Compensation details are confidential and not specified in this posting. For information on compensation, please contact the hiring manager.

Schedule

The role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. Alternating locations may be considered based on commuting distance and candidate preference.

Who We Are

Carelon is a healthcare services organization committed to integrating physical, behavioral, social, and pharmacy services to make care more personalized, affordable, and effective. As a member of the Elevance Health family, we focus on eliminating unnecessary medical expense spending through our dedicated team of care providers, engineers, data scientists, and other professionals.

How We Work

Elevance Health fosters a culture of advancement and personal/professional growth. We offer a range of market-competitive total rewards, including merit increases, paid holidays, Paid Time Off, and incentive bonus programs. Our values and behaviors guide our strategy and drive our shared success for consumers, associates, communities, and the business.