Navitus Health Solutions

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Phamacy Desk Auditor I

at Navitus Health Solutions

Posted: 6/24/2019
Job Reference #: 5000496374406
Keywords: billing, compliance

Job Description

Requisition Number

1161

Location

Appleton Campus: Appleton, Wisconsin

Other Locations

Requirements

Education:

Pharmacy Technician Certification (CPhT) required.

College degree preferred or equivalent experience required.

Experience:

2-3 years of experience as a certified pharmacy technician in a retail, LTC or home infusion pharmacy setting required. 1-3 years knowledge of pharmaceutical claims adjudication systems or health insurance strongly preferred.

Job Description

Job Summary:

In a post-payment work environment, the Pharmacy Desk Auditor I will review pharmacy claims submission data to identify payment errors, recommend best practices and ensure legal compliance and Navitus PBM adherence to contract agreement rules. This position works collaboratively with the Audit team to meet all contract and internal timelines/deadlines. This role requires knowledge of Pharmacy billing and operational practices. This position is office based, but may include limited travel.

Job Responsibilities:

  • Analyze data sets to trend over time and identify outliers of that data set compared to other pharmacies or standards
  • Audit pharmacy claims, develop claim edits and report results
  • Work closely with internal departments on the monitoring of pharmacy billing patterns and behavior.
  • Prepare written analysis of auditing results
  • Make recommendations to pharmacies for corrective action and process improvement.
  • Evaluate audit results for potential referral to our internal Special Investigations Unit (SIU) which may include fraud, waste and abuse.
  • Ensure auditing processes meet all regulatory and Client contractual requirements.
  • Identify trends and events that impact pharmacy and administrative costs.
  • Participate in process re-design, service improvement, cost reduction and automation.
  • Maintain open lines of communication and an environment of collaboration with other functional areas/departments.
  • Participate in team and department meetings and committees regarding goals, vision, and strategic plans
  • Build and maintain relationships with internal business units and pharmacy service providers
  • Other related duties as assigned.