Manager of Pharmacy Audit Operations - Remote

Our work matters. We help people get the medicine they need to feel better and live well.  We do not lose sight of that. It fuels our passion and drives every decision we make.

Job Posting Title

Manager of Pharmacy Audit Operations - Remote

Job Description

The Manager of Pharmacy Audit Operations oversees Prime's day to day pharmacy audit functions. This position provides cross-department leadership for initiatives impacting assigned audit teams and is responsible for driving the effective execution of pharmacy audit plans, procedures, and downstream collection/adjustment activities in response to audit findings. The Manager of Pharmacy Audit Operations works in collaboration with internal and external stakeholders to prevent and detect fraud, waste and abuse (FWA) and is responsible for evaluating, developing and maintaining processes to support pharmacy billing and regulatory and contractual compliance.

Responsibilities

• Provide work direction to a Pharmacy Audit Operations team related to claim reviews, onsite audits, desktop audits, pharmacy monitoring, and/or clam adjustments; develop performance metrics and drive accountability for department objectives and deliverables; establish a team culture of identifying and implementing process improvements to drive efficiency and innovation
• Provide daily oversight to Pharmacy Audit processes including, but not limited to: setting, reviewing and measuring team performance metrics and standards, creating and maintaining documentation to support audit processes, developing and conducting auditor training, monitoring regulatory and client contractual obligations, identifying trends, and holding staff accountable for the effective communication and education of network pharmacies throughout the audit process following the terms of the applicable Pharmacy Provider Manual
• Manage vendor relationship of pharmacy audit activities, when applicable, ensuring timely resolution of operational and procedural issues
• Determine solutions to audit issues with high complexity, risk and/or reputational impact in partnership with Prime's clients and internal business partners; evaluate new drugs, claim trends and establish outlier identification and prevention metrics, practices and policies
• Collaborate with clients to direct pharmacy audit resources to the activities of highest client value; prioritize pharmacy audit activities by evaluating impact, root cause, state and federal regulations, client commitments and risk; collaborate with internal and external stakeholders, Prime's Legal department, clients, chain pharmacy headquarters and pharmacy administrative service organizations (PSAOs), to remediate identified audit or pharmacy issues
• Ensure escalated pharmacy audit grievances, appeals and disputes are appropriately addressed and oversee the performance improvement of pharmacies placed on the "Watch List" and/or corrective action plans (CAPs)
• Identify pharmacy audit results that may indicate a breach of contract and follow appropriate remediation steps; escalate suspected fraud to Prime's Special Investigations Unit (SIU)
• Manage regulatory reporting and external audit response, such as CMS audit support and client audits as assigned
• Develop and maintain in-depth knowledge of the company's business, industry and regulatory environments; routinely review, assess and respond to new or changing regulatory guidelines received from government agencies; adjust process or practice as required
• Serve as primary decision maker regarding audit processes, team priorities and staff management and development; collaborate with key internal stakeholders to drive process and procedural changes in support of Pharmacy Audit priorities or system enhancements to prevent billing errors and FWA
• Other duties as assigned

Education & Experience

• Bachelor's degree in business, finance, biology or other related field, or the equivalent combination of education and related work experience; HS diploma or GED is required

• 6 years of combined experience in retail pharmacy and/or audit operations
• 1 year of progressive managerial or leadership responsibility
• Must be eligible to work in the United States without need for work visa or residency sponsorship

Must be eligible to work in the United States without the need for work visa or residency sponsorship.

Additional Qualifications

• Change agile; willing and able to adjust individual and team direction based upon changing priorities and business need
• Ability to think critically, problem solve and make decisions while anticipating the broad impact of decisions
• Ability to establish trust, respect and credibility and form close working relationships with individuals at all levels of an organization; collaborates effectively cross-functionally and with clients and other external partners
• Demonstrated ability to distill complex concepts or situations into concise and compelling communications
• Expert communication, negotiation and influencing skills
• Proven ability to maintain discretion and confidentiality

Preferred Qualifications

• National Pharmacy Technician Certification through PTCB or ExCPT (CPhT)
• Certified fraud examiner
• Current pharmacist license in good standing with State Board of Pharmacy
• Prior PBM, retail pharmacy, health plan, or health care experience
• Expert level understanding of point of sale and on-line pharmacy claims processing environment

Physical Demands

• Ability to travel up to 15% of the time
• Constantly required to sit, use hands to handle or feel, talk and hear
• Frequently required to reach with hands and arms
• Occasionally required to stand, walk and stoop, kneel, and crouch
• Occasionally required to lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds
• Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus

Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.

Potential pay for this position ranges from $94,000.00 - $160,000.00 based on experience and skills.

To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits at a glance" button for more detail.

Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (pregnancy, sexual orientation, and gender identity), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law.   

We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law.

Prime Therapeutics LLC is a Tobacco-Free Workplace employer.

Positions will be posted for a minimum of five consecutive workdays.

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