Pharmacy Audit Analyst

Location: Remote (For Non-Local) or Hybrid (Local to NYC area)
Position Responsibilities:
* Ability to travel 1-3 weeks each month to perform on-site audits.
* Support desk and/or daily audits for Capital Rx as needed when not performing on-site audits or support functions for these audits.
* Work with internal departments to further develop processes to improve the accuracy of high-risk claims selection that are recommended for outreach and/or audit.
* With support from claim scoring algorithms, select claims that will be audited in accordance with provider agreements and state law requirements.
* Provide insight and expertise to improve any processes related to audit functions and claim selection algorithms.
* Work with internal departments including Customer Care, Client Account Management, Clinical, Compliance, and Finance teams as needed on any Pharmacy Audit-related issues.
* Support investigations and refer providers to the Special Investigations Unit or Pharmacy Evaluation Committee in cases of suspected FWA.
* Perform various aspects of audits including reviewing claim data, sending audit notice to provider, follow-up outreach as needed, review of prescription information, submission of audit findings, appeal review, and submission of final findings.
* Review state/federal/local pharmacy laws and provider agreements as applicable in consultation with legal or regulatory teams as needed to ensure state and/or federal guideline adherence.
* Provide other assistance as assigned by the Provider Relations team.
* Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.
Required Qualifications:
* Nationally Certified Pharmacy Technician (CPhT or similar equivalency)
* Bachelors degree preferred.
* 4+ years of experience in healthcare, audit, provider relations, pharmacy, or other relevant experience
* Intermediate level of proficiency with Microsoft Office products
* Proven track record of working in a fast-paced environment, managing multiple tasks at once and having a go-get attitude to provide persistent outreach to pharmacy providers to close out tasks.
* Ability to work independently, track work/projects appropriately and remain on task.
* Strong communication skills with the ability to develop effective working relationships with providers and internal and external stakeholders.
* At least 1 year of PBM experience required.
Base Salary $45,000 - $55,000
Nothing in this position description restricts managements right to assign or reassign duties and responsibilities to this job at any time.
About Capital Rx
Capital Rx is a full-service pharmacy benefit manager (PBM) and pharmacy benefit administrator (PBA), advancing our nations electronic healthcare infrastructure to improve drug price visibility and patient outcomes. As a Certified B Corp, Capital Rx is executing its mission through the deployment of JUDI, the companys cloud-native enterprise health platform, and a Single-Ledger Model, which increases visibility and reduces variability in drug prices. JUDI connects every aspect of the pharmacy ecosystem in one efficient, scalable platform, servicing millions of members for Medicare, Medicaid, and commercial plans. Together with its clients, Capital Rx is reimagining the administration of pharmacy benefits and rebuilding trust in healthcare.
Capital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.