Pharmacy Auditor - Payment Integrity Complex and Clinical Audit
Core
Auditing high-cost drug, home infusion, dialysis, and DME claims to ensure accurate billing and reimbursement according to contracts and payer policies.
Role type
Licensed pharmacist payment integrity auditor
Builds
Accurate claim payments and audit findings letters for medical benefit plans
Domain
Healthcare insurance / Pharmacy benefit management
Deliverable
client delivery
Required skills
Registered pharmacist license, clinical pharmacy knowledge, medical coding expertise, contract pricing analysis, audit tool utilization, documentation review, aberrant coding pattern recognition
Preferred skills
Managed care experience, specialty pharmacy experience, home infusion/DME/dialysis billing experience
Technologies
Audit tools, claims payment systems
Responsibilities
Screen and select high-cost claims for audit, analyze paid claims data to identify overpayments, request and review supporting documentation, price claims using contract systems, generate audit findings letters, identify coding and documentation errors, develop process improvement recommendations