Program Integrity Auditor – Remote

IQVIA; Atlanta (GA); Remote; USD 50,000 - 54,000; Full time

Job summary

An established industry player is seeking a detail-oriented individual to join their team as a Pharmacy Claims Auditor. In this role, you will be responsible for conducting audits, collaborating with pharmacy facilities, and ensuring compliance with program business rules. Your strong problem-solving and communication skills will be essential as you navigate complex claims and provide corrective actions. This role offers a dynamic work environment where you can make a significant impact on patient outcomes and contribute to innovative healthcare solutions. If you thrive under pressure and enjoy working independently, this opportunity is perfect for you.

Qualifications

• Experience in a customer care environment.
• Ability to interpret Explanation of Benefits (EOB).
• Previous auditing experience.

Responsibilities

• Conduct pharmacy claims audits and document findings.
• Collaborate with pharmacy facilities for claims compliance.
• Evaluate regulations and assist in internal audit activities.

Skills

Problem-solving skills

Communication skills

Customer relationship skills

Time management skills

Organizational skills

Adaptability to new technologies

Ability to work under pressure

Team orientation

Education

High School diploma or equivalent

Bachelor’s Degree

HIPAA certification

Tools

MS Office applications

Job description

**Role Responsibilities**

This individual will report to the Program Integrity Associate Manager and act as a shared resource in collaboration with various program teams to review both chain and independent pharmacy audit requests.

**Principal Accountabilities:**

1. Responsible for conducting pharmacy claims audits at the request of operations and management teams. May leverage healthcare providers, medical facilities, billing portals, and contracting teams as necessary.
2. Collaborate with pharmacy facilities to acquire and review documentation necessary for assessing and validating claims compliance against program business rules.
3. Exercise independent judgment to determine appropriate corrective actions for noncompliant claims, notify pharmacies of findings, and provide instructions for corrective measures, including reversal, refund, or reprocessing of claims.
4. Document all details related to claims audits and summarize findings for management teams.
5. Provide interpretation and consultation to project teams regarding project-specific guidelines, policies, and procedures.
6. Evaluate regulations, customer requirements, SOPs, and project guidelines to assist in planning, conducting, reporting, and closing internal audit activities, as time permits.
7. Demonstrate the ability to work independently with minimal supervision.
8. Show exceptional organizational skills.
9. Recognize operational challenges and collaborate on designing solutions.
10. Manage multiple tasks with various deadlines, prioritizing urgent requests effectively.

**Required Skills:**

1. High School diploma or equivalent.
2. Experience in a customer care environment.
3. Strong problem-solving, communication, and telephone skills.
4. Good customer relationship skills.
5. Ability to exercise independent judgment and discretion, escalating issues when necessary.
6. Adaptability to new technologies and assessing their impact within the company.
7. Flexibility to work with the team to ensure timely service delivery.
8. Ability to produce high-quality work under pressure and tight deadlines.
9. Effective time management skills.
10. Strong team orientation with a flexible attitude towards work priorities.
11. Proficiency in MS Office applications.

**Education & Experience Preferred:**

• HIPAA certification.
• Bachelor’s Degree.
• Ability to interpret Explanation of Benefits (EOB).
• Previous auditing experience.
• Pharmacy Technician experience.

IQVIA is a leading global provider of clinical research services, commercial insights, and healthcare intelligence to the life sciences and healthcare industries. We create intelligent connections to accelerate the development and commercialization of innovative medical treatments to help improve patient outcomes and population health worldwide. Learn more at https://jobs.iqvia.com

IQVIA is proud to be an equal opportunity employer. All qualified applicants will receive consideration without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other protected categories. More information at https://jobs.iqvia.com/eoe

The potential base pay range for this role is $50,000-$54,000 annually, with actual offers varying based on qualifications, location, and schedule. Additional incentives, bonuses, and benefits may also be provided.

At IQVIA, we seek diverse talent committed to innovation and impact. Everyone contributes to our goal of improving patient lives globally. Thank you for your interest in growing your career with us.

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