Quality Review and Audit Lead Analyst - Express ...

Job Description Summary Provides advanced professional input to complex Quality Assurance/Audit assignments/projects to identify pharmacy audit risks. Works autonomously, only requiring "expert" level technical support from others. Exercises judgment in the evaluation, selection, and adaptation of both standard and complex techniques and procedures. Utilizes in-depth professional knowledge and acumen to develop models and procedures, and monitor trends, within Quality Review and Audit. Using independent judgement and discretion, may recommend changes in processing procedures. Job Description The Quality Review and Audit Lead Hybrid Auditor is primarily responsible for using analytical skills and audit tools to identify network pharmacy audit risks and develop/execute audit plans and scope of procedures determined necessary to address those risks. Under a moderate level of guidance, this position performs complex on-site network pharmacy audits to correct risks identified, protect client assets, and present findings to key internal and external stakeholders. This role must adhere to department policies, state and federal requirements and client contractual requirements. ESSENTIAL FUNCTIONS Perform efficient and effective network pharmacy claims audits to produce results consistent with departmental policies and critical corporate goals while meeting or exceeding personal production goals. Performance of audits includes obtaining, analyzing, and appraising evidentiary data on which to base an informed, objective assessment of the accuracy and legitimacy of claims audited. Utilizing personal knowledge of medications, prescription validity and available tools including the CSP, Access, Excel, Teradata etc., identify pharmacies and claims representing audit risks and develop an audit plan to identify billing discrepancies, to efficiently and effectively address those risks. Must be able to read and interpret written prescriptions including, but not limited to, sig codes, day supply calculation, prescription drug knowledge, and federal/state laws. . Has full responsibility for handling/ researching complex issues identified during an audit Develop and produce reports as required to meet needs of department management, Account Managers, pharmacies and chain audit contacts, clients and other stakeholders. Providing updates to management on current status of audits including any escalated issues. Analyzes and investigates audit findings submitted by auditors to determine validity of identified discrepancies. Analysis includes, pricing, prior authorization, eligibility, plan set-up, financial and performance guarantees, and adherence to state specific laws. Coordinates with cross-functional departments to obtain appropriate resolution to identified issues. Discusses the audit with the pharmacy, understanding and managing their expectations and working through any limitations that may be experienced. Tracks status and serves as main contact for pharmacies during all audits Prepare for and participate in client communications, including conference calls and on-site meetings, to present status updates of ongoing issues, results of completed audits, etc., for assigned clients. Perform special projects as assigned. Mentor less experienced team members to improve their understanding and skills by ensuring they are familiar with resource materials including manuals and systems. Responsible for the training of new associate auditors on departmental processes. QUALIFICATIONS Bachelor's degree or equivalent experience. Valid driver's license. Travel up to 25% 2+ years of pharmacy technician experience in a retail, long term care, specialty, mail order or similar pharmacy setting Certified Pharmacy Technician (CPhT) Preferred Proficient in database and spreadsheet applications, ie: Microsoft Excel, Access, Word. Excellent organizational, interpersonal, and communication skills. Ability to work well with all levels of internal and external contacts. Ability to handle sensitive or confidential information is critical. Ability to work with minimum management oversight while performing on-site audits. Ability to work a flexible schedule to accommodate project deadlines. Willingness to travel. If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload. For this position, we anticipate offering an annual salary of 65,600 - 109,400 USD / yearly, depending on relevant factors, including experience and geographic location. This role is also anticipated to be eligible to participate in an annual bonus plan. We want you to be healthy, balanced, and feel secure. That's why you'll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you'll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group. About Evernorth Health Services Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives. Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws. If you require reasonable accommodation in completing the online application process, please email: for support. Do not email for an update on your application or to provide your resume as you will not receive a response. The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State. Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.

Created: 2024-11-19