Pharmacy Claims Auditor I (San Diego)

Pharmacy Network Compliance Auditor

MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team!

Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare.

At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution!

Summary

Responsible for conducting retail pharmacy network compliance audits and credentialing to ensure compliance with government regulations and decrease fraud. Document and make adjustments to pharmacy claims as determined by audit findings to ensure the integrity and accuracy of the MedImpact's claims processes by participating pharmacies. Ensures timely credentialing of participating providers by ensuring that records for each network pharmacy are complete and up-to-date.

Essential Duties And Responsibilities Include The Following. Other Duties May Be Assigned.

• Prepares and completes desktop, document & verification, 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;
• Analyzes pharmacy profile reports for possible claim discrepancies, fraud, and drug abuse;
• Prepares prescription listings for desktop, document & verification, and on-site audits as appropriate;
• Performs extensive follow-up inspection of claims data based on extrapolations from initial audit results;
• Prepares correspondence for 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;
• Ensures that results are appropriately documented for clients and that appropriate invoicing of services is completed;
• Maintains credentialing policies & procedures, work instructions, and documentation processes. Educates stakeholders on credentialing requirements and processes;
• Facilitates credentialing committee meetings by preparing credentialing information for presentation to the committee, maintaining records of action items, following through on committee decisions, and maintaining thorough documentation of committee activities;
• Ensures timely credentialing and re-credentialing of participating providers by ensuring that records for each network pharmacy are complete and up-to-date. Ensures that ineligible providers are excluded from network participation as required by state and federal regulations;
• 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.

Supervisory Responsibilities

No supervisory responsibilities

Client Responsibilities

This is an internal and external client facing position that requires excellent customer service skills and interpersonal communication skills. One must be able to; manage difficult or emotional client situations; Respond promptly to client needs; Solicit client feedback to improve service; Respond to requests for service and assistance from clients; Meet commitments to clients.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and / or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Education And / Or Experience

BS / BA and 2+ years' experience or equivalent combination of education and experience

Computer Skills

Intermediate to advanced skill set in MS Office (Word, Excel, PowerPoint, Project, and Outlook) required. Familiarity with relational database systems and SQL software front ends such as Business Objects highly desirable. Intermediate to advanced skill set in MedAccess, MedOptimize and SalesForce preferred. Strong aptitude to learn and adapt to new programs.

Certificates, Licenses, Registrations

Pharmacy Technician license or national certification highly desired, but not required. Possession of a valid driver's license and ability to provide a certificate of insurance indicating adequate auto insurance limits (as defined by MedImpact Healthcare Systems, Inc.).

Other Skills And Abilities

Reasoning Ability

Mathematical Skills

Language Skills

Competencies

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit and talk or hear. The employee is regularly required to stand; walk; use hands to finger, handle, or feel and reach with hands and arms. The employee must occasionally lift and / or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

This position may regularly be exposed to or encounter moving mechanical parts, high, precarious places, fumes or airborne particles, toxic or caustic chemicals, outdoor weather conditions, risk of electrical shock or vibration. The noise level in the work environment is usually moderate (examples : business office with computers and printers, light traffic).

Work Location

This position works on-site at the San Diego Headquarters or other company location (or from a remote location with management approval based on business requirements). Must provide adequate support to internal clients; be available for regular interactions and coordination of work with other employees, colleagues, clients, or vendors; as well as be available to facilitate effective decisions through collaboration with stakeholders.

Working Hours

This is a full-time non-exempt position requiring one to be able to work overtime from time to time in order to get the job done. Therefore, one must have the ability to work nights, weekends or on holidays as required. This may be changed at any time to meet the needs of the business