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Pharmacy Benefit Auditor
3 weeks ago
The Pharmacy Benefit Setup Auditor plays a crucial role in recognizing, interpreting, and
evaluating discrepancies and inaccuracies in the pharmacy benefit set up data received. Their
responsibilities include ensuring the timely and accurate configuration of our clients, adhering to
defined audit / setup procedures, and actively participating in quality assurance processes.
Proficiency in the internal systems of our contracted Pharmacy Benefit Managers (PBMs), as
well as our own internal systems, is essential for this role. While direct interaction with external
customers may not be involved, effective communication skills, the ability to manage tasks
independently, and a knack for analytically resolving complex issues are vital traits. The
individual must diligently follow process documentation to maintain accuracy while also
leveraging critical thinking skills when required.
Duties & Responsibilities:
Manage concurrent client projects efficiently, ensuring timely completion of critical setup,
case management, and quality assurance tasks within client implementation or benefit
change workflows.
Test issues and analyze information to determine if client pharmacy benefit changes are
needed.
Conduct audits for client and pharmacy benefit setup in accordance with client pharmacy
benefit audit procedures.
Enter pharmacy benefit details into designated systems following the Client audit
process and procedures.
Recognize, interpret, and evaluate inconsistencies, discrepancies and inaccuracies in
the pharmacy benefit set up data received and alert the proper party for resolution.
Conduct initial review of incumbent plan documents and data input for new client
implementations, adhering to prescribed systems.
Specialize in essential steps supporting various project types including new client
pharmacy benefit implementations, medical vendor changes, eligibility modifications,
Third Party Administrators (TPA) transitions, Pharmacy Benefit Managers (PBM) shifts,
and different benefit change requests.
Responsible for the execution of key steps related to minor/routine pharmacy benefit
changes.
Generate configuration documents such as Pharmacy Benefit Manager specific
documents.
Know and adhere to HIPPA regulations
Perform Quality Assurance (QA) testing according to standard procedures and report
findings for client implementations and existing client pharmacy benefit changes.
Conduct comprehensive audits and testing of all phases and features of the client
solution to identify and resolve issues.
Use Microsoft Excel to complete structure comparisons.
Use Microsoft Access to create test case details to apply for automated testing.
Acquire proficiency in Pharmacy Benefit Manager (PBM) documentation, software, and
reporting systems for contracted Pharmacy Benefit Managers.
Document precise test results, including issue locations, screenshots, and member
examples when necessary.
Apply knowledge of RxBenefits and PBM products/features to support incoming work
requests
Manage and document day-to-day work activities within a project management software
tool
Navigate various tools and technologies efficiently.
Deliver work in a production-based environment, meeting standards for timeliness and
accuracy.
Support key projects ensuring client setup accuracy, including Client Audit work or
similar assignments beyond the primary Q4 'busy season.'
Achieve KPI (Key Performance Indicator) goals set by Operations leadership and
department.
Qualifications and Requirements:
Bachelor’s degree preferred
3+ years of related pharmacy/healthcare experience, medical auditing or coding
experience is preferred
Demonstrated understanding of PBM, Payer and formularies and its relevance in
Pharma business is strongly preferred
SalesForce or Other CRM experience is required
Confluence experience preferred
Proficient in English language skills both written and verbal
Proficient in MS Office (Including Word, Excel, Outlook, SharePoint), advanced Excel
skills (Macros, VLOOKUP, etc.) and basic Microsoft Access skills required
Experience with reporting tools (QLIK, PowerBI, DataNet, Tableau) is preferred
Process minded individual with a strong attention to detail who understands the
importance of following a consistent process to maximize efficiency; quality
A passion for learning and a willingness for taking on new challenges
Must adapt well to change and successfully set and adjust priorities as needed
Possess analytical and critical thinking skill
Must be able to attend 3 weeks of new hire training that follows the US Central Standard
Time (CST) time zone
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