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Buck Buck - Pharmacy Claim Auditor in United States

Description

Buck - Pharmacy Claim Auditor - Healthcare Audit Practice (Virtual or Office Position)

At Buck, we’re focused on helping our clients create a culture of wellbeing, centered around the evolution of each person’s health, wealth, and career. Our creative digital, consulting, and tech-enabled administration solutions are empowering the world’s most forward-thinking companies to embrace the new social contract, re-energize their workforces, and embrace an analytics-led talent marketplace in ways that improve how their people work and live.

Leveraging strong client relationships with key decision makers, our teams deliver exceptional results that confidently push the envelope with unexpected solutions to help our clients accomplish their objectives faster and keep them ahead of the curve. Not surprisingly, we embrace inventive thinkers who make original contributions to the team. We put people first — our people and our clients’ people, and our inclusive and welcoming culture celebrates diversity and individuality.

Explore your next career move with Buck today!

Job Summary: Responsible for performing and supporting Pharmacy Audits (claims, rebates, operational, Medicare, pre/post-implementation, etc.) to validate that the coverage of a claim and the payment of such claim are in compliance with the contractual, regulatory and custom plan guidelines. Additionally, certain audits validate the proper reimbursement of pharmacy rebates from a Pharmacy Benefits Manager (PBM) to a client per the contractual arrangement. This position is client facing and requires an individual who can effectively manage client expectations as well as the ability to manage multiple projects without compromise of accuracy or timeliness.

Key Job Responsibilities/Job Description:

  • Manage and perform audits of pharmacy claim payment data to validate conformance with contractual requirements and plan specifications as assigned.

  • Review and evaluate Administrative Services Agreement between the employer and PBM.

  • Work with dedicated data analytics team to define and translate plan provisions for testing purposes ensuring that scope is in line with the statement of work and client commitments. Review client specific documentation, Summary Plan Description(s) and other documentation, such as copay grids, plan literals, set-up grids, etc., to develop the audit test filters.

  • Complete contract summary or assist with completion of contract summaries as assigned.

  • Evaluate the results of the initial claim data tests and determine valid audit samples for review and response by the PBM.

  • Prepare PBM communications regarding test results, response expectations and clarifications to questions.

  • Prepare and present various client communications, including but not limited to Mid-Point discussion documents and audit status updates.

  • Work collaboratively with PBM to resolve exceptions, review supporting documentation and make final claim error determination.

  • Ensure audit timeline is adhered to and deliver high level of service to clients.

  • Perform Pharmacy Rebate audit as assigned. (Occasional travel to the PBM is required;10-20% travel possible.)

  • Prepare and present detailed audit reports which clearly articulate audit findings and recommendations to PBM and client.

  • Maintain audit project work papers to support audit findings.

  • Work collaboratively within the audit team as well as with internal and external customers.

  • Participate in team meetings, conference calls, Zoom meetings, etc. remotely / locally with administrators and audit team as necessary.

  • Assist with Claims Data Analysis and Quality Assurance as requested.

  • Interact directly with clients and respond to client requests, develop strong relationships with clients.

  • Assist in supporting other auditors, Manager and Practice Leader as requested.

  • Perform special projects or assignments as instructed by supervisor.

  • Attain billable hours objective (apply acquired skills in client-productive ways).

Qualification Requirements:

  • College degree (experience may be considered in waiving the degree requirement)

  • 5+ years’ experience in pharmacy consulting, auditing or other applicable pharmacy industry experience

  • Previous PBM experience a plus.

  • Must demonstrate a high level of pharmacy benefit, claim or benefit administration - Medicare experience a strong plus.

  • Proficient in the use of Microsoft Office Software (i.e., Word, Excel, PowerPoint).

  • Strong organizational skills with ability to manage time effectively and handle changing/conflicting priorities.

  • Attention to detail and ability to clearly explain thought process in reaching documented conclusions.

  • Excellent oral and written skills required.

  • Self-directed individuals who require little supervision and can manage multiple projects effectively to ensure deadlines are met - Team player with a strong work ethic.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability or protected veteran status, or any other legally protected basis, in accordance with applicable law.

At Buck, we’re exclusively focused on helping our clients and their people succeed together. By this, we mean we’re partnering with some of the world's most forward-thinking companies to re-envision and re-design the way that employees work and live. And we’re doing this by finding the right combination of consulting, outsourcing, and technology solutions to help our clients realize the best organizational performance for their businesses while driving positive health, wealth, and career outcomes for their people.

Qualifications

Behaviors

Preferred

  • Detail Oriented: Capable of carrying out a given task with all details necessary to get the task done well

  • Dedicated: Devoted to a task or purpose with loyalty or integrity

Motivations

Preferred

  • Goal Completion: Inspired to perform well by the completion of tasks

  • Self-Starter: Inspired to perform without outside help

Education

Preferred

  • Bachelors or better
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