Pharmacy Network Auditor

Position Summary

The Pharmacy Network Auditor is responsible for the maintenance and growth of the Pharmacy Network Audit program and processes at RxSense, including all internal pharmacy audits, and working closely with external pharmacy audit vendors to ultimately detect, prevent and recover on Fraud Waste Abuse (FWA) occurrences.

The role serves as a subject matter expert within the Company regarding standard monitoring measures, auditing procedures, and best practices. The Auditor assesses risks outlined by audit vendors, performs appropriate audit procedures, and collaborates with pharmacy management to resolve issues in a timely and efficient manner. They draft and communicate audit findings and observations to internal stakeholders such as Finance and Client Success, and provide Quarterly Network Audit Performance Reports to leadership to monitor Audit Program efficacy.

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 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
• Maintain audit documentation, and prepare statistical data for internal stakeholder review and action

Qualifications

• Previous Pharmacy Audit Experience is required, understanding of the processes and industry related guidelines are mandatory
• 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

$74,000 - $110,000