Pharmacy Auditor – Payment Integrity, Clinical Audit

Role Overview

• screening, selecting, and auditing high cost drug (HCD), home infusion therapy (HIT), dialysis, and durable medical equipment (DME) claims
• confirms the services rendered are supported by appropriate documentation
• validates the claim is paid correctly according to the provider’s contract and the payer’s reimbursement policies
• specializes in review of professional and facility claims
• analyzes paid claims data to select claims where overpayments are likely
• requests the appropriate records where necessary
• accurately prices claims using the contract or claims payment systems
• draws on advanced injectable drug expertise
• utilizes audit tools, auditing workflow systems, and reference information to generate audit determinations
• maintains accuracy and quality standards as established by audit management
• identifies potential documentation and coding errors

Requirements

• Requires BS in Pharmacy
• minimum of 5 years of experience in pharmacy, home infusion therapy, dialysis and/or durable medical equipment claim auditing
• requires a registered pharmacist
• Current unrestricted Pharmacist license in applicable state(s) required
• experience conducting medical/drug audits
• managed care experience (health plan/payor environment) with understanding of medical coding
• specialty pharmacy experience, including high-cost/complex therapies, limited distribution networks, and coordination across providers, payers, and manufacturers
• experience with billing/auditing for Home Infusion, DME and/or Dialysis preferred

Benefits

• merit increases
• paid holidays
• Paid Time Off
• incentive bonus programs
• medical
• dental
• vision
• short and long term disability benefits
• 401(k) +match
• stock purchase plan
• life insurance
• wellness programs
• financial education resources