Pharmacy Network Auditor

Essential Duties and Responsibilities

• Evaluate, report, and monitor all aspects pertaining to Pharmacy Network Auditing services
• Serve as a subject matter expert within the Company regarding standard monitoring measures, auditing procedures, and best practices
• Assess the risks outlined by audit vendor, perform appropriate audit procedures, and collaborate with pharmacy management to resolve issues in a timely and efficient manner
• Draft and communicate audit findings and observations to internal stakeholders such as Finance and Client Success
• Provide Quarterly Network Audit Performance Reports to the leadership to monitor Audit Program efficacy
• Screen and summarize authorized vendor audit results in detail prior to initiating claim adjustments
• Review results to determine details of fraudulent, erroneous, or abusive billing activity
• Develop and update Standard Operating Procedures (SOPs) for audit and FWA Programs
• Collaborate with key stakeholders to support pharmacy network initiatives
• Establish and maintain relationships with Implementations, Client Services, Benefit Administration, UAT/QA, IT, Product, Finance, Clinical Departments

Qualifications

• Previous Pharmacy Audit Experience with understanding of the processes and industry related guidelines
• 5+ years of experience in a Retail Pharmacy setting and/or Pharmacy Benefits Management organization
• Strong understanding of the pharmacy claims processing ecosystem
• Strong understanding of pharmacy relationships and NCPDP data extracts
• Proficient knowledge and ability to leverage current reporting tools to identify audit and FWA issues proactively
• Strong understanding of Pharmacy Network Standards and how to manage potential FWA issues via claims data
• Proficient knowledge of URAC and CMS network requirements in addition to Federal and State level auditing network requirements
• Ability to research, analyze and report on audit results and industry trends in FWA
• Proven ability to work independently and drive results
• Detail-oriented, ability to multitask, proactive thinker
• Excellent written and verbal communication skills
• Experience with presenting and or training
• Proficiency in MS Word and Excel

Pay

Salary Range: $74,000 - $110,000