Payer Audit Specialist / Pharmacy

Payer Audit Specialist / Pharmacy

Requirements

• Successful completion of an approved/accredited Pharmacy Technician training program strongly preferred
• 1-3 years of related pharmacy experience in a home care setting
• Basic pharmacy knowledge of reading and interpreting prescriptions and submitting pharmacy claims to PBM payers
• Working knowledge of automated billing systems; experience with CPR+ and Waystar a plus
• Working knowledge and application of metric measurements, basic accounting practices, ICD 10, CPT, HCPCS coding, and medical terminology
• Solid Microsoft Office skills with the ability to type 40+ WPM
• Strong verbal and written communication skills with the ability to independently obtain and interpret information and compose written audit responses
• Strong attention to detail and ability to be flexible and adapt to workflow volumes
• Knowledge of federal and state regulations as it pertains to revenue cycle management, a plus

Responsibilities

• Receives, documents, processes, and tracks all incoming PBM payer audit requests and updates until final resolution is obtained. Responsible for correcting PBM claim audit deficiencies and resubmitting claims back to the payer as needed
• Responsible for cross training and providing support to handle incoming payer medical audits
• Communicates and coordinates across departments to ensure audits receive the proper review, appeals, and resolution
• Coordinates with other departments to obtain documentation and justification for medical services rendered. Assembles documentation, composes appeal responses, and submits back to payers in the required format
• Responds timely to all PBM payer audit requests and submits responses within payer deadlines
• Analyzes PBM payer audit trends and communicates concerns and process improvement needs to the RCM Ancillary Services management team
• Records payer audit responses utilizing the appropriate subject headers and templates in CPR+ and the Payer Audit Tracking spreadsheet
• Utilizes most efficient resources to submit PBM payer audits, giving priority to electronic solutions
• Maintains CPR+ Document Management system to include faxing, scanning, and attaching documents
• Oversees the PBM Test Claim report and works to resolve rejected submissions to avoid erroneous payments
• Assists with pulling manufacturer invoices needed for PBM and medical audits
• Reviews PBM credit balances and works with payer to resolve through payer refunds or using Amerita’s approved adjustment codes

Preferred Qualifications

• Pharmacy Technician experience is strongly preferred