Program Integrity Auditor – Remote

IQVIA Argentina; 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 conduct audits, collaborate with pharmacy facilities, and ensure compliance with program business rules. Your ability to exercise independent judgment and manage multiple tasks will be crucial in delivering high-quality work under tight deadlines. This position offers an exciting opportunity to contribute to the healthcare sector while working in a supportive and dynamic environment. If you have a passion for problem-solving and customer care, this role is perfect for you.

Qualifications

• Experience in customer care and problem-solving.
• Ability to work under pressure and manage tight deadlines.

Responsibilities

• Conduct pharmacy claims audits and validate compliance.
• Document audit details and provide summaries to management.

Skills

Problem Solving

Communication Skills

Customer Relationship Skills

Organizational Skills

Time Management

Education

High School Diploma

Bachelor's Degree

Tools

MS Office

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:

• Responsible for conducting pharmacy claims audits at the request of operations and management teams. May leverage health care providers, medical facilities, various billing portals, and contracting teams, as necessary.
• Responsible for collaboration with pharmacy facilities to acquire and review documentation necessary for assessing and validating compliance of claims against program business rules.
• Exercise independent judgment to determine appropriate corrective action of noncompliant claims, notify pharmacies of findings, and provide instructions on the appropriate corrective action. This can include potential reversal, refund, or reprocessing of claims.
• Document all details pertaining to claims audits and provide a summary to appropriate management team members.
• Provide interpretation and consultation to project teams on project specific guidelines/instructions and policies and procedures.
• Evaluate applicable regulations/guidelines, customer requirements, Standard Operating Procedures (SOPs) and project specific guidelines/instructions to assist with planning, scheduling, conducting, reporting and closing internal audit activities, as time permits.
• Self-starter able to carry out job responsibilities with minimal supervision.
• Possess exceptional organizational skills.
• Capable of recognizing operational challenges and collaborating with team to design solutions.
• Requires the ability to handle multiple simultaneous tasks with various deadlines while prioritizing urgent requests.

Required Skills

• High School diploma or equivalent
• Previous experience working in a customer care environment
• Excellent problem solving, telephone and communication skills
• Good customer relationship skills
• Ability to exercise independent judgment, appropriate discretion, and escalate to management as appropriate.
• Ability to rapidly adapt to new technologies and assess their potential impact and usefulness in diverse areas within the company
• Ability to work flexibly with the team to ensure timely delivery of service
• Ability to produce high quality work under pressure and within tight timescales
• An ability to work within tight deadlines and manage time effectively.
• Strong team player with flexible attitude to work priorities.
• Excellent computer skills (MS Office applications)

Education & Experience Preferred:

• HIPPA certified
• Bachelor’s Degree Preferred
• 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 athttps://jobs.iqvia.com

IQVIA is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by applicable law. https://jobs.iqvia.com/eoe

The potential base pay range for this role is $50,000-$54,000 annually. The actual base pay offered may vary based on a number of factors including job-related qualifications such as knowledge, skills, education, and experience; location; and/or schedule (full or part-time). Dependent on the position offered, incentive plans, bonuses, and/or other forms of compensation may be offered, in addition to a range of health and welfare and/or other benefits.