Pharmacy Network Auditor

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

📋 Description

• The Pharmacy Network Auditor is tasked with overseeing and enhancing the Pharmacy Network Audit program and its processes at RxSense.

• Evaluates, reports, and monitors all elements related to Pharmacy Network Auditing services.

• Acts as a subject matter expert on standard monitoring measures, auditing procedures, and best practices.

• Evaluates risks identified by audit vendors, carries out necessary audit procedures, and works with pharmacy management to ensure effective issue resolution.

• Prepares and communicates audit findings to internal stakeholders; delivers Quarterly Network Audit Performance Reports to leadership.

• Reviews and summarizes authorized vendor audit results.

• Analyzes results to detect fraudulent, erroneous, or abusive billing practices.

• Examines claims data for potential investigational FWA breaches by network pharmacies.

• Maintains audit documentation and compiles statistical data for review and action.

• Develops and revises Standard Operating Procedures for audit and FWA Programs.

• Collaborates with key stakeholders to advance pharmacy network initiatives.

⛳️ Requirements

• Prior experience in Pharmacy Auditing is essential, with a solid understanding of industry-related processes and guidelines.

• A minimum of 5 years of experience within a Retail Pharmacy environment and/or Pharmacy Benefits Management organization.

• Comprehensive knowledge of the pharmacy claims processing ecosystem.

• Strong understanding of pharmacy relationships as well as NCPDP data extracts.

• Proficient in utilizing current reporting tools to proactively identify audit and FWA concerns.

• Strong grasp of Pharmacy Network Standards and the management of potential FWA issues through claims data.

• Knowledgeable about URAC and CMS network requirements, along with Federal and State level auditing network standards.

• Capable of researching, analyzing, and reporting on audit outcomes and industry trends in FWA.

• Demonstrated ability to work independently and achieve results.

• Detail-oriented with the capacity to multitask and think proactively.

• Exceptional written and verbal communication skills.

• Experience in delivering presentations and/or training sessions.

• Proficient in MS Word and Excel.

🏝️ Benefits

• RxSense values the power of collaboration, creativity, and the sense of community that a diverse workforce offers.