Analyst, Pharmacy Contract Audit

ISHE; Boise (ID); Remote; USD 70,000 - 90,000; Full time

Benefits offered by this job

Health insurance

Dental insurance

Vision insurance

20 days paid time off

4 weeks parental leave

9 paid holidays

401K company match up to 5%

Adoption Assistance Program

Flexible Spending Account

Educational Assistance Plan and Pro/fi

Referral Bonus Program up to $750

Job summary

Navitus Health Solutions is seeking an Analyst, Pharmacy Contract Audit to oversee the contract reimbursement accuracy across Retail, Specialty, and Mail Order networks. You will review claims data, audit price changes, monitor compliance with provider contracts, and report findings to cross-functional teams.

The role supports the Provider Relations team, working with NCRx and PC2 systems to validate contractual terms and drive remediation of errors.

Qualifications

• Bachelor's degree or equivalent experience required.
• Minimum two years analytics experience required.
• Participate in, adhere to, and support compliance program objectives.
• The ability to consistently interact cooperatively and respectfully with other employees.

Responsibilities

• Analyze and resolve pricing inquiries from providers, clients, auditors, and internal teams focusing on root causes.
• Interpret contract language to compare pricing to adjudicated claims activity.
• Develop and maintain controls and oversight reporting for end-to-end contract pricing across Retail, Specialty, and Mail Order.
• Test pharmacy network rates, conduct chain audits, and assess impact of changes.
• Submit service or recovery requests and coordinate system updates as needed.
• Follow and improve current operational processes; share results with Provider Services and leadership.

Skills

Analytics

Communication

Education

Bachelor's degree or equivalent experience

Job description

Overview

Due to growth, we are adding a Analyst, Pharmacy Contract Audit to our team! The Analyst, Pharmacy Contract Audit is responsible for the oversight of Navitus' contractual pharmacy network reimbursement accuracy. The individual in this position is expected to make independent assessments to confirm Navitus is conforming to contractual reimbursement obligations contained in Retail, Specialty, and Mail Order pharmacy agreements. The Analyst will continually review and monitor claims data, create, and update procedures, audit networks for price change accuracy, monitor compliance with Navitus pharmacy provider contracts, communicate findings, and work with applicable teams to remediate errors. The Analyst works closely with inter and intra-departmental resources to interpret and understand contractual terms, client network selections, and how they are operationalized in applicable systems. The Analyst will be knowledgeable of business operations, utilizing Navitus' adjudication system (NCRx) and contracting and credentialing databases (PC2), among other applications. Provider, client, and network performance will be analyzed in support of network development, quality control, and compliance with contractual terms, including effective rate and other aggregate tracking mechanisms. As part of the Provider Relations team, the Analyst will be responsible for creating an array of reports to validate systems accuracy to Retail, Specialty, and Mail Order contractual terms.

Responsibilities

How do I make an impact on my team?

• Analytical and operational understanding of Navitus' reimbursement programs including AWP, WAC, MAC, NADAC, FUL, AAC, Average Dispensing Fee, and other pricing structures


• Responsible for fielding, analyzing, and resolving inquiries from pharmacy providers, clients, auditors, and internal teams regarding Retail, Specialty, and Mail Order pricing errors with focus on the root cause


• Interpret pharmacy contract language to compare Retail, Specialty, and Mail Order contract pricing to adjudicated claims activity


• Develop and maintain appropriate controls and oversight reporting on the end-to-end process of Retail, Specialty, and Mail Order contract pricing. If process controls are absent, the expectation is to identify, define, and implement new processes as needed


• Responsible for pharmacy network rate testing, chain audits, analysis, and impact assessment


• Make decisions regarding the resolution of pharmacy network pricing setup issues


• Submit service requests, recovery requests, and/or engage applicable teams to make system updates/changes


• Understand, follow, and improve current operational and administrative processes


• Periodic and detailed reporting of contractual compliance activities and opportunities to Provider Services team and cross-functional leadership


• Other duties as assigned

Qualifications

What our team expects from you?

• Bachelor's degree or equivalent experience required. Emphasis in business, finance, economics, or operations preferred


• Minimum two years analytics experience required


• Participate in, adhere to, and support compliance program objectives


• The ability to consistently interact cooperatively and respectfully with other employees

What can you expect from Navitus?

• Top of the industry benefits for Health, Dental, and Vision insurance


• 20 days paid time off


• 4 weeks paid parental leave


• 9 paid holidays


• 401K company match of up to 5% - No vesting requirement


• Adoption Assistance Program


• Flexible Spending Account


• Educational Assistance Plan and Professional Membership assistance


• Referral Bonus Program up to $750!

Remote

Navitus Health Solutions is an Equal Opportunity Employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, creed, sex, pregnancy, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, veteran status, or any other characteristic protected by law.