AmeriHealth Caritas Jobs

Job Information

AmeriHealth Caritas Pharmacy Network Auditor in Philadelphia, Pennsylvania

Pharmacy Network Auditor

Location: Philadelphia, PA

Primary Job Function: Pharmacy

ID**: 19164

Job Brief

  • Conduct desktop and onsite audits for pharmacies within the PerformRx Pharmacy Network

  • Active/current National Pharmacy Technician Certification (i.e., ExCPT, NCCT, PTCB) required

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com .

Summary:

Under the general observation of the Manager of Pharmacy Network Operations, the Pharmacy Network Auditor assists the Manager in the evaluation, reporting and monitoring of all aspects pertaining to Pharmacy Network auditing services.

Responsibilities:

  • Conduct desktop and onsite audits for pharmacies within the PerformRx Pharmacy Network and in accordance with Federal, State, and Internal Audit standards

  • Within the general guidelines provided by the Pharmacy Network Audit management, will assess the risks in the pharmacy audit assignment, perform appropriate audit procedures; draft and communicate audit findings and observations; and collaborate with pharmacy management to resolve issues in a timely and efficient manner

  • Analyze claims data for potential investigational FWA breaches of network pharmacies; after reviewing, the Auditor shall determine details of fraudulent, erroneous, or abusive billing activity on Real Time Application System and various reports

  • Will identify and document fraudulent or erroneous activities determined as a result of their work

Education/Experience:

  • High School Diploma or equivalent required

  • Associate’s degree preferred, or equivalent experience

  • Current/recent auditing experience preferred

  • Active/current National Pharmacy Technician Certification (i.e., ExCPT, NCCT, PTCB) required

  • Certified Fraud Examiner preferred

  • In-depth knowledge of pharmacy operations

  • Long-Term Care (LTC) or Specialty Pharmacy experience

  • Understanding of URAC and CMS network requirements

  • Understanding of State level network requirements

  • Understanding of Federal and State level auditing network requirements

  • Strong communication skills (listening, verbal and written)

EOE Minorities/Females/Protected Veterans/Disabled

DirectEmployers