Pharmacy Contract Audit Analyst

This is a fully remote position, open to applicants in United States.

📋 Description

• Supervise the accuracy of reimbursement within Navitus’ contractual pharmacy network.

• Conduct independent assessments to ensure compliance with reimbursement obligations outlined in Retail, Specialty, and Mail Order pharmacy agreements.

• Review and analyze claims data regularly.

• Develop and revise procedural documentation as needed.

• Perform audits to confirm the accuracy of price changes.

• Monitor adherence to pharmacy provider contracts.

• Communicate findings and collaborate with relevant teams to correct any discrepancies.

• Interpret contractual terms, client network selections, and their implementation in relevant systems.

• Utilize Navitus’ adjudication system (NCRx) along with contracting and credentialing databases (PC2) and other applications.

• Analyze performance metrics for providers, clients, and networks to support network development, quality assurance, and compliance with contracts.

• Generate reports to validate system accuracy against the contractual terms of Retail, Specialty, and Mail Order.

• Address, analyze, and resolve inquiries regarding pricing errors from pharmacy providers, clients, auditors, and internal teams, with an emphasis on identifying root causes.

• Create and uphold controls and oversight reporting for contract pricing.

• Identify, define, and implement new processes in the absence of established controls.

• Conduct testing of pharmacy network rates, chain audits, and impact assessments.

• Submit service and recovery requests, engaging applicable teams for system modifications or updates.

• Report on contractual compliance activities and opportunities to the Provider Services team and cross-functional leadership.

• Carry out additional duties as assigned.

⛳️ Requirements

• A Bachelor’s degree or equivalent experience is required.

• A focus in business, finance, economics, or operations is preferred.

• At least two years of analytics experience is essential.

• A solid analytical and operational understanding of Navitus’ reimbursement programs, including AWP, WAC, MAC, NADAC, FUL, AAC, Average Dispensing Fee, and other pricing structures.

• Capability to interpret pharmacy contract language and compare contract pricing against adjudicated claims activity.

• Proficiency in developing and maintaining controls and oversight reporting.

• Competence in performing pharmacy network rate testing, chain audits, analyses, and impact assessments.

• Ability to make informed decisions regarding pharmacy network pricing setup issues.

• Understanding, following, and improving operational and administrative processes is essential.

• Participation in, adherence to, and support of compliance program objectives is necessary.

• A consistent ability to interact cooperatively and respectfully with fellow employees.

• Must be able to work remotely from an eligible US state; remote work is not available to residents of Alaska, Hawaii, Maine, Mississippi, New Hampshire, New Mexico, North Dakota, Rhode Island, South Carolina, South Dakota, West Virginia, and Wyoming.

🏝️ Benefits

• Comprehensive industry-leading benefits for Health, Dental, and Vision insurance.

• 20 days of paid time off.

• 4 weeks of paid parental leave.

• 9 paid holidays.

• 401K company match of up to 5% with no vesting requirement.

• Adoption Assistance Program.

• Flexible Spending Account.

• Educational Assistance Plan and support for Professional Memberships.

• Referral Bonus Program offering up to $750!

• Monday to Friday, 8:00am-5:00pm work schedule.