[Hiring] Pharmacy Network Auditor @RxSense

Role Description

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.

• Evaluates, reports, and monitors all aspects pertaining to Pharmacy Network Auditing services.
• Serves as a subject matter expert regarding standard monitoring measures, auditing procedures, and best practices.
• Assesses risks outlined by audit vendor, performs appropriate audit procedures, and collaborates with pharmacy management to resolve issues in a timely and efficient manner.
• Drafts and communicates audit findings and observations to internal stakeholders such as Finance and Client Success.
• Provides Quarterly Network Audit Performance Reports to leadership to monitor Audit Program efficacy.
• Screens and summarizes authorized vendor audit results in detail prior to initiating claim adjustments.
• Reviews results to determine details of fraudulent, erroneous, or abusive billing activity.
• Leverages current BI Tools to analyze claims data for potential investigational FWA breaches of network pharmacies.
• Maintains audit documentation and prepares 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.
• Establishes and maintains relationships with Implementations, Client Services, Benefit Administration, UAT/QA, IT, Product, Finance, and Clinical Departments 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.

Requirements

• Salary Range: $74,000 - $110,000.

Benefits

• RxSense believes that a diverse workforce is a more talented and productive workforce.
• Equal Opportunity and Affirmative Action employer.
• Recruitment process is free from discriminatory hiring practices.
• All qualified applicants are considered for employment without regard to race, color, religion, sex, gender, sexual orientation, gender identity, ancestry, age, or national origin.
• Qualified applicants will not be discriminated against on the basis of disability or protected veteran status.
• Belief in the strength of collaboration, creativity, and sense of community a diverse workforce brings.