Pharmacy Network Auditor

Position Summary:

The Pharmacy Network Auditor is responsible for the maintenance and growth of the Pharmacy Network Audit program and processes at RxSense, including all internal pharmacy audits, and working closely with external

pharmacy audit vendors to ultimately detect, prevent and recover on Fraud Waste Abuse (FWA) occurrences.The Pharmacy Network Auditor is solely responsible for assuring compliance with client contract requirements,

pharmacy contractual compliance, and effectively communicating the program updates in real-time to leadership.

Essential Duties and Responsibilities:

To perform this job successfully, an individual must be able to perform the following satisfactorily; other duties may be assigned. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Pharmacy Network Auditor evaluates, reports and monitors all aspects pertaining to Pharmacy Network Auditing services

The role will also serve as a subject matter expert within the Company regarding standard monitoring measures, auditing procedures, and best practices

Assess the risks outlined by audit vendor, perform appropriate audit procedures, and collaborate with pharmacy management to resolve issues in a timely and efficient manner

Draft and communicate audit findings and observations to internal stakeholders such as Finance and Client Success; Provide Quarterly Network Audit Performance Reports to the leadership to monitor Audit Program efficacy

Screen and summarize authorized vendor audit results in detail prior to initiating claim adjustments

Review results to determine details of fraudulent, erroneous, or abusive billing activity

Responsible for leveraging current BI Tools to analyze claims data for potential investigational FWA breaches of network pharmacies

Maintain audit documentation, and prepare statistical data for internal stakeholder review and action

Develops and updates Standard Operating Procedures (SOPs) for audit and FWA Programs

Collaborates with key stakeholders to support pharmacy network initiatives

Establish and maintain relationships with Implementations, Client Services, Benefit Administration, UAT/QA, IT, Product, Finance, Clinical Departments with focus on actively engaging the appropriate teams to enhance the Audit/FWA program

Qualifications:

Previous Pharmacy Audit Experience is required, understanding of the processes and industry related guidelines are mandatory

5+ years of experience in a Retail Pharmacy setting and/or Pharmacy Benefits Management  organization

Strong understanding of the pharmacy claims processing ecosystem

Strong understanding of pharmacy relationships and NCPDP data extracts

Proficient knowledge and ability to leverage current reporting tools to identify audit and FWA issues proactively

Strong understanding of Pharmacy Network Standards and how to manage potential FWA issues via claims data

Proficient knowledge of URAC and CMS network requirements in addition to Federal and State level auditing network requirements

Ability to research, analyze and report on audit results and industry trends in FWA

Proven ability to work independently and drive results

Detail-oriented, ability to multitask, proactive thinker

Excellent written and verbal communication skills

Experience with presenting and or training

Proficiency in MS Word and Excel

Salary Range: $74,000 - $110,000