Quality Review And Audit Senior Analyst

This role is responsible to complete day-to-day Quality Review and Audit tasks without immediate supervision, but has ready access to advice from more experienced team members.
Identify pharmacy audit risks using analytical skills and Audit tools and develop and execute audit plans and scope of procedures determined necessary to address those risks. This position will assist in the completion of pharmacy claims audits in order to correct risks and provide internal and external communication of the audit findings. This role must adhere to department policies, state and federal requirements and client contractual requirements.
ESSENTIAL FUNCTIONS
-Assists the audit team with sorting and filing audit documentation containing PHI. Monitor the audit email and voicemail boxes with outreach response adhering to policy.
Utilize current programs and analytical procedures and existing tools, including Outlook, excel, , while utilizing personal knowledge of medications to identify clients, members and claims representing financial risks.
Pharmacy claims review to identify billing discrepancies resulting in claim adjudication and correction. Responsibility for reprocessing pharmacy claims with identified discrepancies.
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.
Analyzes audit findings to determine validity of any identified Has full responsibility for handling/ researching complex issues identified during an audit. Prepare formal and thorough written reports providing findings of the audits performed within the timeline required.
Responsibility for providing ad hoc reports to key business owners.
special projects as assigned and as needed.
Top 3 Skills:
Pharmacy Technician experience, Computer Skills such as excel, word, outlook.
Retail Pharmacy Technician
Ability to translate written prescriptions / SIG Codes
Microsoft Outlook
MS Excel
MS Word
Strong Written and Verbal Communication Skills
Strong Time Management and Organizational Skills
HIPAA