Pharmacy Auditor - Payment Integrity Complex and Clinical Audit

• Specializes in review of professional and facility claims with separate line-level payments for high cost drugs, home infusion therapy, renal claims, and durable medical equipment.
• Analyzes paid claims data to select claims where overpayments are likely, requests the appropriate records where necessary, and accurately prices claims using the contract or claims payment systems.
• Draws on advanced injectable drug expertise, mastery of pharmacy domain clinical knowledge, and industry knowledge to substantiate conclusions.
• Utilizes audit tools, auditing workflow systems, and reference information to generate audit determinations and formulates detailed audit findings letters.
• Maintains accuracy and quality standards as established by audit management.
• Identifies potential documentation and coding errors by recognizing aberrant coding and documentation patterns such as inappropriate units, excessive units, inappropriate or missing modifiers, excessive frequency, payments allowed in excess of the contract, excessive waste, equipment rentals that exceed the units billed.
• Suggests and develops high quality, high value, concept and or process improvement and efficiency recommendations.

• Requires BS in Pharmacy and minimum of 5 years of experience in pharmacy, home infusion therapy, dialysis and/or durable medical equipment claim auditing; or any combination of education and experience, which would provide an equivalent background.
• Requires a registered pharmacist.
• Current unrestricted Pharmacist license in applicable state(s) required.

• Experience conducting medical/drug audits.
• Managed care experience (health plan/payor environment) with understanding of medical coding.
• Specialty pharmacy experience, including high-cost/complex therapies, limited distribution networks, and coordination across providers, payers, and manufacturers.
• Experience with billing/auding for Home Infusion, DME and/or Dialysis preferred.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact [email protected] for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act