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Pharmacy Auditor

  • Job Family: Medical and Clinical
  • Type: Full time
  • Date Posted:
  • Anticipated End Date:
  • Reference: JR103595

Location:

  • OH, MASON
  • MA, BOSTON
  • VA, NORFOLK

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Description

Pharmacy Auditor

Schedule: 1-2 days per week in the office (Hybrid 1)

Location: This position will work a hybrid model (remote and office). The ideal candidate will live within 50 miles of an Elevance Health PulsePoint location.

The Pharmacy Auditor is responsible for screening, selecting, and auditing high-cost drug (HCD), home infusion therapy (HIT), dialysis and durable medical equipment (DME) claims to ensure they are billed accurately to the medical benefit. Confirms the services rendered are supported by the appropriate documentation and validates the claim is paid correctly according to the provider’s contract and the payer’s reimbursement policies. Specializes in review of professional and facility claims with separate line-level payments for high-cost drugs, home infusion therapy, renal claims, and durable medical equipment.

How you will make an impact:

  • Analyzes paid claims data to select claims where overpayments are likely, requests the appropriate records where necessary, and accurately prices claims using the contract or claims payment systems.
  • Draws on advanced injectable drug expertise, mastery of pharmacy domain clinical knowledge, and industry knowledge to substantiate conclusions.
  • Utilizes audit tools, auditing workflow systems and reference information to generate audit determinations and formulates detailed audit findings letters.
  • Maintains accuracy and quality standards as established by audit management.
  • Identifies potential documentation and coding errors by recognizing aberrant coding and documentation patterns such as inappropriate units, excessive units, inappropriate or missing modifiers, excessive frequency, payments allowed in excess of the contract, excessive waste, equipment rentals that exceed the units billed.
  • Suggests and develops high quality, high value, concept and or process improvement and efficiency recommendations.

Minimum Requirements

  • Requires BS in Pharmacy and minimum of 5 years of experience in pharmacy, home infusion therapy, dialysis and/or durable medical equipment claim auditing; or any combination of education and experience, which would provide an equivalent background.
  • Requires a registered pharmacist and must possess an active unrestricted state license to practice pharmacy as a Registered Pharmacist (RPh).

Preferred Skills, Capabilities and Experiences

  • Prior experience in claims and pricing platforms preferred.

 

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.comfor assistance.

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