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

• 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