Pharmacy Claims Auditor I

MedImpact Healthcare Systems Inc.; San Diego (CA); On-site; USD 34,000 - 56,000; Full time

Benefits offered by this job

Medical / Dental / Vision / Wellness

Paid Time Off / Holidays

Incentive Compensation

401K with Company match

Life and Disability Insurance

Tuition Reimbursement

Employee Referral Bonus

Job summary

MedImpact Healthcare Systems, Inc. in San Diego, CA is seeking a Compliance Auditor to conduct desk and onsite audits of network pharmacies, verify credentials, and ensure regulatory compliance across federal, state, and contract requirements.

You will review claims data, document findings, communicate results to pharmacies, and support client invoicing with accurate, timely reporting.

Qualifications

• BS/BA and 2+ years’ experience or equivalent combination of education and experience.
• Intermediate to advanced MS Office (Word, Excel, PowerPoint, Project, Outlook).
• Familiarity with relational databases and SQL front ends is desirable.

Responsibilities

• Prepares and completes Pre-Pay reviews, desk and onsite audits to evaluate compliance.
• Analyze pharmacy profile reports for discrepancies, fraud, and drug abuse.
• Prepare prescription requests for audits as appropriate.
• Execute in-depth claims data examinations to identify patterns and outcomes.
• Develops audit outcome reports and correspondence for pharmacies.

Skills

Audit analysis

Regulatory knowledge

Communication

Data interpretation

Education

BS/BA and 2+ years’ experience

Tools

MS Office

SQL

MedAccess & MedOptimize

Job description

Exemption Status

United States of America (Non-Exempt) $25.33 - $41.16

Pay scale information is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any selected candidate or employee, which is always dependent on actual experience, education, qualifications, and other factors. A full review of our comprehensive pay and benefits will be discussed at the offer stage with the selected candidate.

This position is not eligible for Sponsorship.

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!

Job Description Summary

Responsible for conducting compliance desk or onsite audits of retail, mail order, specialty, compound & long-term care (LTC) network pharmacies. Verifies pharmacy credentials to ensure compliance with applicable government regulations, contractual requirements and MedImpact standards. Reviews, documents and adjusts pharmacy claims based on audit findings to ensure the integrity and accuracy of the MedImpact’s claims processes by network pharmacies. Ensures audits are completed in a timely manner and credentialing of participating providers by ensuring that records for each audit are complete and up to date.

Essential Duties and Responsibilities

• Prepares and completes Pre-Pay reviews, desk and/or and onsite audits to evaluate compliance with contractual, regulatory, and pharmacy practice requirements including obtaining and analyzing claim data, reviewing prescription hardcopy, assessing dispensing and billing practices, reviewing applicable federal, state, and local pharmacy regulations, documenting audit findings, communicating results to pharmacies, and developing audit plans, schedules, and travel arrangements as needed
• Analyze pharmacy profile reports for possible claim discrepancies, fraud, and drug abuse
• Prepares prescription requests for Pre-Pay, desk, and onsite audits as appropriate
• Executes in-depth claims data examinations following preliminary audit findings to identify patterns, validate exceptions, and quantify audit outcomes
• Draft and distribute provider communications requesting documentation to verify compliance with contractual, regulatory, and billing requirements identified through claim review activities
• Evaluates audit documentation and processes claim adjustments based on validated audit findings and compliance with laws and regulation requirements
• Develops audit outcome reports and supporting correspondence for pharmacies, clearly documenting findings, recoveries, and corrective actions as applicable
• Ensures results are appropriately documented & communicated to clients, while ensuring accurate and timely invoicing of services completed
• Maintains audit & credentialing policies & procedures, work instructions, and documentation processes. Educates stakeholders on requirements and processes
• Adheres to department guidelines for escalation of issues, including provider non-compliance
• Follows protocol for notifying management of potential fraud, waste, and abuse.
• Ensures that critical issues related to pharmacy audit, 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 (listening/verbal/written).

• 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 preferred. Strong aptitude to learn and adapt to new programs.

Certificates, Licenses, Registrations

Pharmacy Technician license or national certification (PTCB) required. Pharmacy and/or pharmacy audit experience 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

Ability to read and interpret hand-written prescriptions. Knowledge of medications and standard dosages. Strong knowledge of the practice of pharmacy, including applicable federal and state laws, regulatory requirements, prescription dispensing processes, and documentation standards. Self-motivated professional with strong decision-making, organizational, and follow-through skills, capable of working independently with minimal direction. Strong interpersonal and verbal and written communication skills with the ability to effectively navigate challenging situations while maintaining professionalism, tact, and diplomacy. maintain tact and diplomacy in difficult situations. Performs highly complex analytical work requiring exceptional attention to detail, accuracy, and independent judgment. Utilizes business acumen, industry knowledge, and technical expertise to evaluate risks, ensure compliance, and make recommendations that support organizational and client objectives while minimizing operational and financial exposure. Reasoning Ability Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Mathematical Skills Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations. Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs. Language Skills Ability to write reports, business correspondence, and procedure manuals. Ability to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community.

Competencies

Composure Decision Quality Organizational Agility Problem Solving Customer Focus Drive for Results Peer Relations Time Management Dealing with Ambiguity Learning on the Fly Political Savvy

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. The typical working hours for this position are Monday through Friday from 8:00am to 5:00pm.

Travel

This position requires domestic travel of up to 10% of the time.

Perks

• Medical / Dental / Vision / Wellness Programs
• Paid Time Off / Company Paid Holidays
• Incentive Compensation
• 401K with Company match
• Life and Disability Insurance
• Tuition Reimbursement
• Employee Referral Bonus

About MedImpact

MedImpact, is a privately-held pharmacy benefit manager (PBM) headquartered in San Diego, California. Our solutions and services positively influence healthcare outcomes and expenditures, improving the position of our clients in the market. MedImpact offers high-value solutions to payers, providers and consumers of healthcare in the U.S. and foreign markets.

Equal Opportunity Employer, Male/Female/Disabilities/Veterans OSHA/ADA:

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

Disclaimer: The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.

MedImpact was founded more than three decades ago by a pharmacist and independent drug store owner who saw firsthand how families struggled with the high cost of prescriptions, and how it impacted their lives, financial security, and health. So, he started MedImpact to make prescription benefits understandable and accessible. While we have grown to be one of the leading PBMs in America, we remain as committed to these principles today as we did when it all began.