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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

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