Exemption Status:
United States of America (Non-Exempt)
$25.33 - $33.25 - $41.16
“Pay scale information is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any selected candidate or employee, which is always dependent on actual experience, education, qualifications, and other factors. A full review of our comprehensive pay and benefits will be discussed at the offer stage with the selected candidate.”
This position is not eligible for Sponsorship.
MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team!
Why join MedImpact? 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 MedImpact, 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 MedImpact standards. Reviews, documents and adjusts pharmacy claims based on audit findings to ensure the integrity and accuracy of the MedImpact’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…