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, with flexibility for the rest of the week. Responsibilities Screen, select, and audit high cost drug (HCD), home infusion therapy (HIT), dialysis, and durable medical equipment (DME) claims. Confirm that services rendered are supported by documentation and that claims are paid correctly per provider contracts and payer reimbursement policies. Analyze paid claims data, identify potential overpayments, request necessary records, and accurately price claims. Utilize audit tools and workflow systems to generate audit determinations and formulate detailed audit findings letters. Maintain accuracy and quality standards as established by audit management. Identify documentation and coding errors such as inappropriate units, excessive modifiers, or payments that exceed contract limits. Suggest and develop high‑quality process improvement and efficiency recommendations. Minimum Requirements B.S. in Pharmacy and minimum of 5 years of experience in pharmacy, home infusion therapy, dialysis, and/or DME claim auditing; or equivalent combination of education and experience. Registered pharmacist with a current unrestricted pharmacist license in the applicable state(s). Preferred Skills, Capabilities and Experiences Experience conducting medical/drug audits. Managed‑care experience in a health plan/payor environment and understanding of medical coding. Specialty pharmacy experience, including high‑cost/complex therapies and coordination across providers, payers, and manufacturers. Experience with billing/auditing for Home Infusion, DME and/or Dialysis. Job Details Job Level: Non‑Management Exempt Workshift: 1st Shift (U.S.) Job Family: MED > Licensed/Registered Pharmacist/Pharmacy Technician Equal Employment Opportunity Elevance Health is an Equal Employment Opportunity employer. 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 should submit the Accessibility Accommodation Request Form. #J-18808-Ljbffr The Elevance Health Companies, Inc.