XTN-7AC7989 | PHARMACY AUDIT SUPPORT REPRESENTATIVE

The Pharmacy Audit Support Representative is responsible for analyzing and monitoring pharmacy claims to ensure compliance with Pharmacy rules and regulations along with state and federal guidelines. Communicate with network pharmacies to verify and/or request adjustments to pharmacy claims as determined by audit support findings to ensure the integrity and accuracy of MedImpact’s claims data.

• Health Insurance/HMO
• Enjoy unlimited MadMax Coffee
• Diverse learning & growth opportunities
• Accessible Cloud HR platform (Sprout)
• Above standard leaves

Essential Duties and Responsibilities include but are not limited to the following. Other duties may be assigned by Management.

• Reviews and analyzes claims data against pharmacy policy/procedures and knowledge of prescription medications to determine details of fraudulent or incorrect billing activity.  Uses MIDAS Claims Software as well as MedImpact internally-developed systems and reports to accomplish work deliverables.
• Communicates with pharmacies to ensure proper billing activity, claims data verification and request claim adjustments as needed.  
• Performs and finalizes audit support findings including obtaining claim data for verification and accuracy. Reviews dispensing activities for billing errors; reviews federal/state/local pharmacy laws, documents audit support results, and notifies pharmacies as needed.
• Documents all telephone conversations and keeps record of faxes with pharmacies and Corporate Contacts for Chain Pharmacies.
• Prepares correspondence to pharmacy providers, requesting documentation to validate potential claim discrepancies.  
• Reviews documentation and makes appropriate claim adjustments according to audit support findings.  
• Adheres to the department’s guidelines for escalation of issues, including provider non-compliance.
• Follows department’s protocol for notifying management of potential fraud, waste, and abuse.  Ensures critical issues related to pharmacy credentialing and continuing network participation are recognized, documented, and addressed. 
• Performs report preparation, participation in special projects, problem resolution and other activities that support the “Provider Audit” process.

Supervisory Responsibilities                                              

• This job has 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.

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 required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience                                            

• High school diploma (or equivalent) required; prefer Associates degree or some college coursework.
• Requires 1+ years’ pharmacy experience and 1+ years’ administrative/clerical experience in an office or customer service environment.   

Computer Skills

• Requires working knowledge of MS Office (Word, Excel), use of e-mail and familiarity with database software. 

Certificates, Licenses, Registrations

• Pharmacy Technician license, Certified Pharmacy Technician (CPT) and/or National certification, not required, but preferred.  

Reasoning Ability                                                    

• Ability to solve practical problems and deal with a variety of variables in situations where only limited standardization exists.
• Ability to interpret instructions furnished in written, oral, diagram, or schedule form.

Mathematical Skills                                                 

• Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume.
• Ability to apply concepts of basic algebra and geometry.

Language Skills                                           

• Ability to read, analyze, and interpret general business periodicals, or governmental regulations.
• Ability to read reports, and business correspondence. 

Competencies                                  

• To perform the job successfully, an individual should demonstrate the following competencies:

Adaptability - Adjusts quickly to evolving situations by integrating new information, remaining flexible, recognizing and implementing necessary changes and taking advantage of opportunities presented by new developments.

Communication - Expresses self clearly and effectively in face-to-face interactions, presentations and written documents, and employs active listening skills to ensure productive interactions.

Customer and Quality Focus - Actively demonstrates a personal concern for understanding client needs, ensuring the quality of products and services, maintains a high level of customer satisfaction, and contributes to continuous improvement of products and processes.

Productivity - Achieves high-quality, concrete results, completing tasks quickly and responding to problems as they arise in order to ensure that deadlines and production goals are met.

Professionalism - Acts with integrity, shows self to be reliable and responsible, displays emotional intelligence, and conscientiously complies with all relevant laws, policies, and procedures.

Quantitative Skills - Competently uses quantitative abilities appropriate for the job, such as basic math skills, interpretation of spreadsheets, or use of charts, graphs and statistics. 

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit and talk or hear. The employee is frequently required to use hands to finger, handle, or feel and reach with hands and arms. The employee is occasionally required to stand; walk and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Work Location (Remote or Company Offices)

This position works either on-site at one of MedImpact’s offices (San Diego, SRO, GLO) or at a remote location as agreed upon with management for purposes of providing adequate support to internal clients.  Maintains availability during office hours for client interactions and coordination of work with other employees, colleagues, clients, or vendors; as well as for facilitation of quick and effective decisions through collaboration with stakeholders. 

Work Environment 

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is occasionally exposed to moving mechanical parts; fumes or airborne particles and risk of electrical shock. The noise level in the work environment is usually moderate.

Working Hours

This is a non-exempt position requiring one to be able to work overtime from time to time in order to get the job done.  Therefore, one must have the ability to work nights, weekends or on holidays as required.  This may be changed at any time to meet the needs of the business.  The typical working hours for this position are Monday through Friday from 8:00am to 5:00pm.

Travel - This position requires domestic travel with overnight requirements for periods of up to one (1) week at a time.

• Ability to read and interpret hand-written prescriptions.
• Knowledge of medications and standard dosages. 
• Strong knowledge of the practice of pharmacy, including statutory laws, regulations, and methods of filling and filing prescriptions. 
• Ability to work independently with minimal direction and strong decision-making ability.  Strong organizational and follow-through skills. 
• Strong interpersonal, oral, and written communication skills with the ability to maintain tact and diplomacy in difficult situations.