Pharmacy Desktop Auditor

Become a part of our caring community and help us put health first

Pharmacy Desktop Auditor associate is responsible for reviewing pharmacy claim submissions and prescription documentation to determine accuracy of dispensing. Conduct pharmacy outreach to resolve claims and provide pharmacy support and education. Research and investigate pharmacy trends to identify potential prescription misbilling and pharmacy waste and abuse. Require researching and understanding of pharmacy state and federal requirements. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.

Follows established guidelines/procedures.

• Perform desktop audits targeting potential pharmacy waste and error

• Review prescription documentation provided by pharmacies, perform comparative analysis against claim billing submissions, document and explain any discrepancies or inaccuracies, respond to pharmacy inquiries and facilitate education of adjustments and changes.

• Conduct pharmacy outreach to make courtesy calls on upcoming due dates, serve as point of contact for pharmacy questions related to audits, and educate on correct claim submissions

• Analyzes and monitors pharmacy industry trends impacting pharmacy business

• Adhere to all applicable requirements for audit process and quality

• Prepares reports and presentations based on audits results

• Collaborates with the team to support overall FWA prevention and detection efforts and ensure audit quality

• Provides ideas and recommendations on process improvements

• Work on special projects as assigned

• Maintain Pharmacy Technician Certification including learning industry changes and completing CE’s required to renew certification.

• Perform specific audit-related functions within the Audit program which can include calling on suspicious claim submissions, performing state specific law research and quality assurance.

• Must be currently certified by the PTCB (Pharmacy Technician Certification Board) and maintain certification

• 2+ years of experience working as a pharmacy technician in a retail or hospital setting

• Experience working independently and researching/conducting investigations; must be analytical, self-motivated, goal oriented and have the ability to successfully investigate complex issues

• In - depth knowledge of pharmacy operations

• Microsoft Office Applications (Word - creating and editing documents, Excel - creating and maintain spreadsheets)

• Strong verbal and written communication skills, including the ability to tailor communication to audience

• Strong organizational and time management skills

• Ability to handle multiple tasks, meet deadlines, and follow-up timely

• Previous experience with pharmacy benefits management

• 2+ years of experience in a position processing pharmacy claims and/or investigating fraud (health care fraud investigations experience preferred)

• Bachelor's degree

• An intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to health insurance (Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy and/or commercial health insurance)

Travel:
While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours
40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$65,000 - $88,600 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Humana offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana…