JOB SUMMARY
The Claims Auditor is responsible for maintaining the execution of pharmacy claims auditing to detect and resolve client fraud, waste, and abuse (FWA) accurately. This position has no direct reports. The incumbent is also required to perform all tasks in observance of Rite Aid’s brand and strategy and adhere to our core values and service attributes.
JOB RESPONSIBILITIES
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Perform analysis of prescriptions and other pharmacy related documentation to verify accuracy and validity of billed claims. Accurately document findings.
Research and analyze data related to pharmacy claims independently
Adhere to quality and productivity standards per department procedures
Maintain dashboard assignments in timely manner according to inventory
Identify and refer pharmacies with billing and/or documentation concerns to Special Investigations Unit for additional corrective action
Compile documentation in relation to pharmacy claims audits as it relates to departmental activities
Maintain accurate documentation of pharmacy audit (or project) progress in order to provide accurate and timely feedback to supervisory personnel
Accurate maintenance and organization of contact database and audit documentation
Communicate with doctors, pharmacies and patients, according to audit needs
Assist with research and assembly of reporting documents for clients, CMS, and internal use
Participate in Continuing Education training and webinars to enhance working knowledge of health care FWA
Develop and report department audit results
Other duties as assigned
REQUIREMENTS:
High school diploma or GED
Certified, Licensed, or Registered Pharmacy Technician
Pharmacy technician experience
Proficient in Microsoft Office and industry related software programs
Strong attention to detail and accuracy
Effective verbal and written communication skills
Ability to exercise considerable judgement, maintain confidentiality, and act in diplomatic manner
An excellent facilitator who is experienced in resolving conflicts between different parties to a dispute
A decisive individual who possesses a detail oriented perspective
Sound technical skills, analytical ability, good judgment, and strong operational focus
Ability to work with peers in a team effort
Demonstrated ability to manage multiple priorities and deadlines
A well-organized and self-directed individual who is able to work with minimal amount of supervision
Capability to efficiently complete tasks in a fast paced environment
Ability to work extended hours, weekends, and holidays pursuant with industry demands
PREFERRED QUALIFICATIONS:
Bachelor’s degree in health administration, health sciences or related field
Demonstrated pharmacy claims auditing experience
Medicare Part D knowledge
Pharmacy claims analysis experience
Bilingual in English and Spanish
PBM experience
WORK ENVIRONMENT:
Includes a typical office environment, with minimal exposure to excessive noise or adverse environmental issues.
PHYSICAL REQUIREMENTS:
Ability to sit for prolonged periods of time.
EDUCATION REQUIREMENTS
Education Level
H.S. Diploma or General Education Degree (GED)
Bachelor Degree
Area of Specialization (Marketing, Finance, Pharmacy, Engineering/IT, etc)
health administration, health sciences or related field
LICENSES/CERTIFICATIONS
Licenses/Certifications
Other/List/Reason
Pharmacy Technician
KNOWLEDGE, SKILLS AND ABILITIES
Knowledge, Skills and Abilities
· Proficient in Microsoft Office and industry related software programs
Strong attention to detail and accuracy
· Effective verbal and written communication skills
· Ability to exercise considerable judgement, maintain confidentiality, and act in diplomatic manner
· An excellent facilitator who is experienced in resolving conflicts between different parties to a dispute
· A decisive individual who possesses a detail oriented perspective
· Sound technical skills, analytical ability, good judgment, and strong operational focus
· Ability to work with peers in a team effort
· Demonstrated ability to manage multiple priorities and deadlines
· A well-organized and self-directed individual who is able to work with minimal
amount of supervision
· Capability to efficiently complete tasks in a fast paced environment
· Ability to work extended hours, weekends, and holidays pursuant with industry demands
Medicare Part D knowledge
Bilingual in English and Spanish
WORK EXPERIENCE
Experience
Areas of Experience (Pharmacy, Compliance, E-commerce, Retail, etc)
Pharmacy Technician
Pharmacy Claims Auditing
Pharmacy Claims Analysis
PBM
QUALIFICATIONS
The typical starting pay range for this position is between $20.00-$27.50 an hour although wages can vary based on experience and geography.
