Quality Review and Audit Lead Analyst - Express Scripts - Remote

Job Description Summary

Provides advanced professional input to complex Quality Assurance/Audit assignments/projects to identify pharmacy audit risks.

Works autonomously, only requiring "expert" level technical support from others.

Exercises judgment in the evaluation, selection, and adaptation of both standard and complex techniques and procedures.

Utilizes in-depth professional knowledge and acumen to develop models and procedures, and monitor trends, within Quality Review and Audit.

Using independent judgement and discretion, may recommend changes in processing procedures.

Job Description

The Quality Review and Audit Lead Hybrid Auditor is primarily responsible for using analytical skills and audit tools to identify network pharmacy audit risks and develop/execute audit plans and scope of procedures determined necessary to address those risks.

Under a moderate level of guidance, this position performs complex on-site network pharmacy audits to correct risks identified, protect client assets, and present findings to key internal and external stakeholders.

This role must adhere to department policies, state and federal requirements and client contractual requirements .

ESSENTIAL FUNCTIONS


* Perform efficient and effective network pharmacy claims audits to produce results consistent with departmental policies and critical corporate goals while meeting or exceeding personal production goals.

Performance of audits includes obtaining, analyzing, and appraising evidentiary data on which to base an informed, objective assessment of the accuracy and legitimacy of claims audited.



* Utilizing personal knowledge of medications, prescription validity and available tools including the CSP, Access, Excel, Teradata etc., identify pharmacies and claims representing audit risks and develop an audit plan to identify billing discrepancies, to efficiently and effectively address those risks.


* Must be able to read and interpret written prescriptions including, but not limited to, sig codes, day supply calculation, prescription drug knowledge, and federal/state laws.

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Has full responsibility for handling/ researching complex issues identified during an audit



* Develop and produce reports as required to meet needs of department management, Account Managers, pharmacies and chain audit contacts, clients and other stakeholders.

Providing updates to management on current status of audits including any escalated issues.


* Analyzes and investigates audit findings submitted by auditors to determine validity of identified discrepancies.

Analysis includes, pricing, prior authorization, eligibility, plan set-up, financial and performance guarantees, and adherence to state specific laws.

Coordinates with cross-functional departments to obtain appropriate resolution to identified issues.


* Discusses the audit with the pharmacy, understanding and managing their expectations and working through any limitations that may be experienced.

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