Prepares and completes desk and on-site audits, including obtaining claim data for selection analysis, reviewing dispensing activities for billing errors, reviewing federal/state/local pharmacy laws, documenting audit results, notifying pharmacies, and preparing travel
itineraries, audit plans, & schedules as appropriate;
Reviews and analyzes claims data against pharmacy policy/procedures and knowledge of prescription medications to determine details of fraudulent or incorrect billing activity.
Uses MIDAS Claims Software as well as MedImpact internally-developed systems and reports to accomplish work deliverables.
Communicates with pharmacies to ensure proper billing activity, claims data verification and request claim adjustments as needed which includes, but not limited to: (1) Making outbound calls to pharmacies verifying claim accuracy and support billing adjustments, and (2) Following-up with pharmacies by faxing and emailing related documents.
Analyzes pharmacy profile reports for possible claim discrepancies, and fraud, waste, and abuse.
Prepares prescription listings for desk and on-site audits as appropriate.
Performs extensive follow-up inspection of claims data based on extrapolations from initial audit results.
Prepares correspondence to pharmacy providers, requesting documentation to validate detected claim discrepancies.
Reviews documentation and makes appropriate claim adjustments according to audit findings.
Prepares audit outcome documentation for pharmacies.
Documents results and that appropriate client invoicing is completed for services.
Adheres to unit guidelines for escalation of issues, including provider non-compliance.
Follows unit protocol for notifying management of potential fraud, waste, and abuse.
Ensures that critical issues related to pharmacy credentialing and continuing network participation are recognized, documented, and addressed according to department guidelines.
Performs report preparation, participation in special projects, problem resolution and other activities that support the provider auditing process.

PHARMACY CLAIMS AUDITOR

PHARMACY CLAIMS AUDITOR

KMC Employee

A Friend of KMC

RECRUITMENT PROCESS