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Pharmacy Network Audit Analyst

Company: PDMI
Location: Youngstown
Posted on: August 9, 2019

Job Description:

PDMI is seeking a Pharmacy Network Audit Analyst to join our team!Summary: This position is responsible for leading the tracking, monitoring, and managing the successful completion of pharmacy and claim audits from beginning to end. The position is also responsible for developing and enhancing the processes used to complete audits, including working with vendors and other internal resources.In the performance of their respective duties and responsibilities, all PDMI employees are expected to conform to the following:Perform quality work within deadlines with or without direct supervision.Interact professionally with other employees, customers, and providers.Work effectively as a team contributor on all assignments.Work independently while understanding the necessity for communicating and coordinating work efforts with other employees, teams, and departments.Essential Duties and Responsibilities include the following. To perform this job successfully, an individual must be able to perform each essential function satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Other duties may be assigned.Audit Operations (80%):Be the lead liaison for clients and pharmacies as it relates to the audit procedures.Coordinate internal and external requests related to Rx audits.Provide complete and coherent audit reporting content for end users.Lead the internal Audit Committee for final results recommendations.Execute recoveries in a detail and timely fashion as the result of any applicable audit.Compile new internal queries and claim identification methods to identify potential Fraud Waste and Abuse that may otherwise be missed.Support Client Services in addressing any audit functions related to a client's potential needs.Support Pharmacy Networks in addressing any audit functions in potential pharmacy contracts.Develop and maintain an expert level of Medicare Part D compliance understanding for future.Develop quality assurance standards to meet and exceed industry best practices.Create and publish policies and procedures to maintain highest standards for all aspects of audit.Attend industry conferences, trade shows, and meetings (e.g., NCPDP) as necessary for continuing education.Other duties as assigned.Audit Analytics (15%):Compile new internal queries and claim identification methods to identify potential Fraud Waste and Abuse that may otherwise be missedCorporate Development (5%):Gain level of understanding related to Pharmacy Network compliance as well as related legislation affecting PBM industry.Attend industry conferences, trade shows, and meetings (e.g., NCPDP) as necessary for continuing educationCompetencies, Skills And Other RequirementsVery strong analytical attention to detailMaintains focus to ensure completion of all aspects of a provided taskA well-organized and self-directed individual who is able to work with minimal amount of supervisionExcellent organizational and time management skillsAbility to function effectively and professionally in a fast-paced environmentAbility to multi-task, managing multiple projects/priorities dailyExcellent research skills, follow-up skills, documentation skills, and issue-resolution skillsStrong internal and external presentation and communication skillsAbility to exercise considerable judgment, maintain confidentiality, and act in a diplomatic mannerMotivated to meet and exceed expectationsAbility to communicate effectively with all levels within an organizationAbility to self-develop as rules, regulations, and industry standards change regularlyAbility to work extended hours, weekend, and holidays as needed pursuant to industry demandsPrevious auditing experience preferredStrong Rx claim acumen and pharmacy dispensing industry understanding preferredMedicare Part D compliance knowledge preferredData analysis using various database tools (Excel, SQL) preferredSolid communication skills, verbal, written and listeningDetail-oriented with high degree of accuracy and organizational skillsExcellent investigative, problem resolution, critical thinking, judgment and decision-making skillsSome overnight travel may be requiredRequired QualificationsEducation and/or Experience: Bachelor's Degree in related fieldIn lieu of a degree, a minimum of 3+ years analyst experience, preferably with the pharmacy or healthcare industryExperience driving initiatives/projectsExperience conducting analysis and using supporting data to make informed decisionsExperience in development of process and proceduresMicrosoft Office skills, including Word, Access, PowerPoint, and OutlookAdvanced working knowledge of MS ExcelPreferred QualificationsWorking knowledge of SQL, VisioPrevious pharmacy claims system experience4+ years Pharmacy Technician experience, auditing, or compliance roleExperience with Medicare Part D and B.Pharmacy Benefit Management (PDM) knowledge/experienceHighly proficient in data analysis reporting tools such as Power BI or other softwareCertificates, Licenses, Registrations Pharmacy Technician Certification preferredPhysical Demands The physical demands described here are representative of the physical requirements necessary for an employee to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the described essential functions.While performing the duties of the job, the employee is regularly required to talk and hear. The employee is frequently required to sit and use their hands and fingers to handle or feel. The employee is occasionally required to stand, walk, and reach with hands and arms. The employee must occasionally lift and/or move up to 50 pounds. Specific vision abilities required by this job include close vision and distance vision.Work Environment The work environment characteristics described here are representative of the environment the employee will encounter while performing the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the described essential functions.This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, telephones, copiers, filing cabinets, and fax machines. The noise level in the work environment is usually quiet to moderate.PDMI (Pharmacy Data Management, Inc.) offers transparent, pass through pharmacy claims processing and pharmacy benefit administration services for private label Pharmacy Benefit Managers (PBMs), vertically integrated health plans and hospital systems. Our proven proprietary systems are flexible and scalable, designed to provide our clients the ability to customize pharmacy benefit solutions to meet their client's needs. Our clients are empowered to choose the services provided by PDMI and which services kept in house. We are independent of wholesalers, mail order pharmacies, and specialty pharmacies, with no hidden agendas, fees,or income. PDMI feels strongly about data ownership and accessibility. It's your data; you own it and you have access 24/7.For over 35 years, we've provided pharmacy claims adjudication services and a suite of pharmacy benefit administrative services that are flexible, scalable solutions to help our clients meet their business objectives. In addition to traditional Pharmacy Benefit Management Services, we offer solutions that include 340B Administration, Hospice, Long Term Care, and Medicare Part D Services.

Keywords: PDMI, Youngstown , Pharmacy Network Audit Analyst, Accounting, Auditing , Youngstown, Ohio

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