MedImpact Healthcare Systems, Inc.
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Formulary Audit Analyst
at MedImpact Healthcare Systems, Inc.
San Diego, CA
# of openings:
Added to system:
12/11/18 4:41 PM
Formulary Audit Analyst
If you’re interested in a career within a customer-focused, team-oriented environment that rewards innovation, quality, integrity and collaboration, MedImpact Healthcare Systems, Inc. welcomes your application. MedImpact, is a privately-held pharmacy benefit manager (PBM) headquartered in San Diego, California. Our solutions and services positively influence healthcare outcomes and expenditures, improving the position of our clients in the market. MedImpact offers high-value solutions to payers, providers and consumers of healthcare in the U.S. and foreign markets.
The Formulary Audit Analyst I ensures thorough research of all claims questions related to client formularies and all Part D programs handled by Formulary Services. This position has an “internal” focus and works with Business Analysts and Program Managers within the Company to accomplish deliverables.
Essential Duties and Responsibilities include the following. Other duties may be assigned.
- Participates in CMS Program and client oversight claims audit reviews; demonstrates production claims processing
- Works closely with internal teams, CMS, Plan Sponsors, and a wide variety of audit firms to provide detailed responses to claims universes questions, audit inquiries and other issues arising for POS adjudication
- Internally facilitates research and responses to claim questions or audit findings; influences formulary management decisions and audit outcomes by providing researched data as well as the basis and support for MedImpact’s position
- Maintains and augments personal knowledge related to changes in state and federal laws including but not limited to CMS guidance, Medicare and Medicaid rules and regulations related to and affecting formulary audits and practices. Understands how MedImpact implements those rules. Applies CMS rules to MedImpact’s practices
- Handles a large volume of formulary audit and formulary PBM oversight support requests through a CRM (Salesforce). Researches MedImpact’s historical handling of scenarios by reviewing claims data, adjudication logic, calculations as well as consulting internal subject matter experts (SMEs)
- Works with Business Analysts to define query parameters (or universes) for data related to claims adjudication, financial calculations, reporting rules, etc. to understand and formulate responses to external entities.
- Explains to a variety of internal audiences claims adjudication rules, technical configuration, the “why” behind CMS rules. Pulls data and runs queries to support audits and to educate others on processes
- Communicates any errors/issues discovered and provides suggestions for impact analysis as appropriate.
- Assists with the development of process improvements for the department that includes reviewing daily processes and providing suggestions to leadership
Education and/or Experience
For consideration, candidates will need a Bachelor degree in a related field or an equivalent combination of education and experience. To perform this job successfully an individual must have a minimum of (3) three to (5) five years’ experience with benefits coding or configuration in Pharmacy Benefit Management (PBM), Pharmacy systems management and claims processing, claims auditing, testing and validation or related Managed Healthcare experience; or an equivalent combination of education and experience. Prior experience required in the healthcare field, PBM or closely related industry. Medicare Part D experience is a plus. Retail pharmacy experience preferred.
- Intermediate to advanced knowledge of MS Office / Word, PowerPoint, and Outlook
- Advanced knowledge of MS Excel
- Working knowledge of key business applications such as SQL queries, Oracle forms, Golden 32, MedAccess, MedAccess Classic, MS Access, MedOptimize, Visio, or others as applicable to the role
- Ability to run SQL queries and scripts
Certificates, Licenses, Registrations
- Current Pharmacy Technician License and/or CPhT certification without restriction preferred
Other Skills and Abilities
- Ability to effectively balance a high volume of work and a variety of tasks
- Ability to prioritize urgent issues effectively
- Strong analytic, verbal and written communication skills
- Detail-oriented with high degree of accuracy and organizational skills
- Able to effectively work as a team player
- Excellent investigative, problem resolution, judgment and decision- making skills required
- Excellent presentation and consultative skills, working with internal and external clients at various levels in the organization.
- Possesses a cross-functional understanding of Part D processes within different departments
- Understands the Medicare Part D and other lines of business configurations at the client level for areas such as Benefits and Pharmacy Networks, Claims Adjudication and Formulary
This position may require occasional travel as well as attendance at local conferences and seminars.
This position is eligible for Employee Referral Bonus at Level I
To perform this job successfully, the successful candidate must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.