Hybrid Pharmacy Integrity Lead (Fraud & Audit)

Horizon Blue Cross Blue Shield of New Jersey; Hopewell (NJ); Hybride; USD 110 000 - 150 000; Plein temps

Avantages offerts par ce poste

Health benefits

Retirement plans

Generous PTO

Incentive plans

Wellness programs

Volunteer time off

Tuition reimbursement

Résumé du poste

Horizon Blue Cross Blue Shield of New Jersey is seeking a PharmD or Pharmacy-educated leader to direct the Pharmacy Fraud, Waste and Abuse program in collaboration with state and federal regulators. You will design PHP edits and oversee audits, training staff and driving program metrics.

The role requires at least 5 years as a registered pharmacist and 3 years in pharmacy auditing, with strong regulatory know-how and leadership in a managed care or PBM setting, with travel across New Jersey.

Qualifications

• Bachelor degree is required in Pharmacy or PharmD from an accredited college or university.
• Minimum of 5 years of recent practice as a Registered Pharmacist, preferably in New Jersey in a retail, PBM, managed care or auditing environment.
• Minimum of three (3) years prior pharmacy auditing experience.

Responsabilités

• Lead the Pharmacy Fraud, Waste and Abuse program in collaboration with regulatory agencies.
• Oversee audits with pharmacy audit vendor and site selection for on-site retail audits.
• Design and implement utilization management programming edits for pharmacy claims.
• Provide staff training on review of high-dollar Medicaid pharmacy claims and reconciliation.
• Educate staff on desktop audit methodologies and reporting to senior leadership.
• Identify POS system edits to mitigate future aberrant claims and expenses.
• Lead on-site audit supervision and vendor coordination.
• Develop processes to identify and suspend payments for excluded/debarred providers.
• Review J and Q code payments for reasonableness and report anomalies.

Connaissances

Pharmacy auditing

Regulatory compliance

Staff training

Communication skills

Formation

Pharmacy degree (B.Pharm or PharmD)

Description du poste

Horizon Blue Cross Blue Shield of New Jersey is seeking a PharmD or Pharmacy-educated leader to direct the Pharmacy Fraud, Waste and Abuse program in collaboration with state and federal regulators. You will design PHP edits and oversee audits, training staff and driving program metrics.

The role requires at least 5 years as a registered pharmacist and 3 years in pharmacy auditing, with strong regulatory know-how and leadership in a managed care or PBM setting, with travel across New Jersey.