Pharmacy Claims Auditor

Med Impact Healthcare Systems, Inc. is looking for extraordinary people to join our team!

Why join Med Impact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare.

At Med Impact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry.

We are the premier Pharmacy Benefits Management solution!#
** Job Description
**** Summary
* * Responsible for conducting compliance desk or onsite audits of retail, mail order, specialty, compound & long-term care (LTC) network pharmacies. Verifies pharmacy credentials to ensure compliance with applicable government regulations, contractual requirements and Med Impact standards. Reviews, documents and adjusts pharmacy claims based on audit findings to ensure the integrity and accuracy of the Med Impact’s claims processes by network pharmacies.

Ensures audits are completed in a timely manner and credentialing of participating providers by ensuring that records for each audit are complete and up to date
** Essential Duties and Responsibilities
** include the following. Other duties may be assigned.
* Prepares and completes Pre-Pay reviews, desk and/or and onsite audits to evaluate compliance with contractual, regulatory, and pharmacy practice requirements Including obtaining and analyzing claim data, reviewing prescription hardcopy, assessing dispensing and billing practices, reviewing applicable federal, state, and local pharmacy regulations, documenting audit findings, communicating results to pharmacies, and developing audit plans, schedules, and travel arrangements as needed
* Analyze pharmacy profile reports for possible claim discrepancies, fraud, and drug abuse
* Prepares prescription requests for Pre-Pay, desk, and onsite audits as appropriate
* Executes in-depth claims data examinations following preliminary audit findings to identify patterns, validate exceptions, and quantify audit outcomes
* Draft and distribute provider communications requesting documentation to verify compliance with contractual, regulatory, and billing requirements identified through claim review activities
* Evaluates audit documentation and processes claim adjustments based on validated audit findings and compliance with laws and regulation requirements
* Develops audit outcome reports and supporting correspondence for pharmacies, clearly documenting findings, recoveries, and corrective actions as applicable
* Ensures results are appropriately documented & communicated to clients, while ensuring accurate and timely invoicing of services completed
* Maintains audit & credentialing policies & procedures, work instructions, and documentation processes.  Educates stakeholders on requirements and processes
* Adheres to department guidelines for escalation of issues, including provider non-compliance
* Follows protocol for notifying management of potential fraud, waste, and abuse.  Ensures that critical issues related to pharmacy audit, credentialing and continuing network participation are recognized, documented, and addressed according to department guidelines
* Performs report preparation, participation in special projects, problem resolution and other activities that support the provider auditing process.
** Supervisory Responsibilities
** No supervisory responsibilities                                   
** Client Responsibilities
** This is an internal and external client facing position that requires excellent customer service skills and interpersonal communication skills (listening/verbal/written).  One must be able to; manage difficult or emotional client situations;
Respond promptly to client needs;
Solicit client feedback to improve service;
Respond to requests for service and assistance from clients;
Meet commitments to clients.#
** Qualifications
* * To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability…