Exemption Status:

United States of America (Non-Exempt)

$25.33 - $33.25 - $41.16

“Pay scale information is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any selected candidate or employee, which is always dependent on actual experience, education, qualifications, and other factors.  A full review of our comprehensive pay and benefits will be discussed at the offer stage with the selected candidate.”

This position is not eligible for Sponsorship.

MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team!

Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare.

At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution!

Job Description

Summary

Responsible for conducting retail pharmacy network compliance audits and credentialing to ensure compliance with government regulations and decrease fraud. Document and make adjustments to pharmacy claims as determined by audit findings to ensure the integrity and accuracy of the MedImpact’s claims processes by participating pharmacies. Ensures timely credentialing of participating providers by ensuring that records for each network pharmacy are complete and up-to-date. 

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Prepares and completes desktop, document & verification, 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;

• Analyzes pharmacy profile reports for possible claim discrepancies, fraud, and drug abuse;

• Prepares prescription listings for desktop, document & verification, and on-site audits as appropriate;

• Performs extensive follow-up inspection of claims data based on extrapolations from initial audit results;

• Prepares correspondence for 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; 

• Ensures that results are appropriately documented for clients and that appropriate invoicing of services is completed;

• Maintains credentialing policies & procedures, work instructions, and documentation processes.  Educates stakeholders on credentialing requirements and processes;

•  Facilitates credentialing committee meetings by preparing credentialing information for presentation to the committee, maintaining records of action items, following through on committee decisions, and maintaining thorough documentation of committee activities;

• Ensures timely credentialing and re-credentialing of participating providers by ensuring that records for each network pharmacy are complete and up-to-date.  Ensures that ineligible providers are excluded from network participation as required by state and federal regulations;

• 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.

Supervisory Responsibilities        

No supervisory responsibilities

                                   

Client Responsibilities

This is an internal and external client faci