Pharmacy Auditor - Payment Integrity Complex and Clinical Audit

Pharmacy Auditor – Payment Integrity Complex and Clinical Audit Location This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office. Hybrid Workforce Policy Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. COVID‑19 and Influenza Vaccination Policy The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member‑facing roles to become vaccinated against COVID‑19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. How you will make an impact Specializes in review of professional and facility claims with separate line‑level payments for high cost drugs, home infusion therapy, renal claims, and durable medical equipment. Analyzes paid claims data to select claims where overpayments are likely, requests the appropriate records where necessary, and accurately prices claims using the contract or claims payment systems. Draws on advanced injectable drug expertise, mastery of pharmacy domain clinical knowledge, and industry knowledge to substantiate conclusions. Utilizes audit tools, auditing workflow systems, and reference information to generate audit determinations and formulates detailed audit findings letters. Maintains accuracy and quality standards as established by audit management. Identifies potential documentation and coding errors by recognizing aberrant coding and documentation patterns such as inappropriate units, excessive units, inappropriate or missing modifiers, excessive frequency, payments allowed in excess of the contract, excessive waste, equipment rentals that exceed the units billed. Suggests and develops high quality, high value, concept and or process improvement and efficiency recommendations. Minimum Requirements Requires BS in Pharmacy and minimum of 5 years of experience in pharmacy, home infusion therapy, dialysis and/or durable medical equipment claim auditing; or any combination of education and experience, which would provide an equivalent background. Requires a registered pharmacist. Current unrestricted Pharmacist license in applicable state(s) required. Preferred Skills, Capabilities and Experiences Experience conducting medical/drug audits. Managed care experience (health plan/payor environment) with understanding of medical coding. Specialty pharmacy experience, including high‑cost/complex therapies, limited distribution networks, and coordination across providers, payers, and manufacturers. Experience with billing/auditing for Home Infusion, DME and/or Dialysis preferred. Benefits We offer a range of market‑competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k)+match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Equal Employment Opportunity Statement Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact View email address on click.appcast.io for assistance. Qualified Applicants With Arrest or Conviction Records Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. Florida Law Screening Information Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration. #J-18808-Ljbffr Elevance Health