PA Audit Analyst I

Exemption Status:

“Pay scale information is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any selected candidate or employee, which is always dependent on actual experience, education, qualifications, and other factors.  A full review of our comprehensive pay and benefits will be discussed at the offer stage with the selected candidate.”

This position is not eligible for Sponsorship.

MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team!

Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare.

At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution!

Job Description

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Works closely with the company’s External Compliance Support team as well as prior authorization, appeals and grievances, and the direct member reimbursement operations teams to assist clients who are undergoing audits.  Collaborates closely with cross functional team members in the Formulary, Client Audit Support and Advisory, Regulatory Compliance areas as a representative of PA Audit Support team on audits that span multiple business units.
• Manages research, responses, and written and verbal communication to questions or audit findings; influences audit outcomes by providing researched data as well as the basis and support for the company’s position.
• Serves as a subject matter expert  for the Compliance department, where designated. CMS audits including but not limited to program audits, data validation audits, and financial audits.
• Understands and keeps current with Medicare Part D, applicable state regulations, and related CMS guidance and rules as well as advises the prior authorizations, appeals and grievances, and direct member reimbursement leadership on all those rules. Applies CMS rules to the organization’s practices; makes recommendations on how the company can implement process improvements.
• Handles a large volume of audit support requests through a CRM (Salesforce).  Researches the organization’s historical handling of scenarios by reviewing prior authorizations, appeals and grievances, and direct member reimbursement cases.
• Explains to a variety of audiences, the “why” behind CMS rules related to prior authorizations, appeals and grievances, and direct member reimbursement.
• Collaborates with the MedOptimize reporting team to design and develop queries for current and future reporting.
• Effectively communicates any potential audit risks discovered internally and externally by providing suggestions to conduct impact analyses, update operational documents, update company policies and procedure, and update systems as appropriate.

Supervisory Responsibilities  

This job has no supervisory responsibilities.

Client Responsibilities

This is an internal and external client facing position that requires excellent customer service skills and interpersonal communication skills (listening/verbal/written).  One must be able to; Respond promptly to compliance audits.; Solicit client and audit firm feedback to improve service; Respond to requests for service and assistance from clients, CMS auditors and consultant audit firms; Meet commitments to compliance audits by a client, regulatory body, or third party contracted by the client or regulatory body.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below 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.

Education and/or Experience    

Bachelor’s degree in a related field or equivalent combination of education and experience and a minimum of two (2) years of experience in the PBM, prior authorization, healthcare fields, or closely related industry experience in audit.

Computer Skills

To perform this job successfully, an individual should have solid computer skills with Microsoft Office Suite (Word/Excel/Outlook), CRM tools (such as Salesforce) and advanced knowledge working with databases.  Skilled with the use of MedOptimize and MedAccess a plus.

Certificates, Licenses, Registrations

Maintains a current Pharmacy Technician License and/or CPhT certification without restriction.  A PMP or CFE certification preferred.

Other Skills and Abilities

Prior authorization, data analysis, and claims research experience preferred. Analytical skills in healthcare data and systems.

Other Skills and Abilities  

• Strong analytical and technical skills (building queries, pulling data, performing data quality control);
• Ability to work under tight deadlines and meet deliverables;
• Excellent verbal/written communication skills;
• Good interpersonal skills including using diplomacy and tact with external auditors and regulatory authorities and in emotionally charged situations;
• Ability to respond to auditor questions and understand/respond to a variety of audit methodologies.

Reasoning Ability                                                    

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Mathematical Skills                                                 

Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume.  Ability to apply concepts of basic algebra.

Language Skills                                           

Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, policies and procedures, and business correspondence. Ability to effectively present information and respond to questions from groups of managers, clients, and customers.

Competencies                                              

To perform the job successfully, an individual should demonstrate the following competencies:

• Composure
• Decision Quality
• Organizational Agility
• Problem Solving
• Customer Focus
• Drive for Results
• Peer Relations
• Time Management
• Dealing with Ambiguity
• Learning on the Fly
• Political Savvy

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit and talk or hear. The employee is frequently required to use hands to finger, handle, or feel and reach with hands and arms. The employee is occasionally required to stand and walk. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.

Working Hours

This is an exempt level position requiring the incumbent to work the hours required to fully accomplish job responsibilities and reasonable meet deadlines for work deliverables. The individual must have the flexibility to work beyond traditional hours and be able to work nights, weekends or on holidays as required.  Work hours may be changed from time to time to meet the needs of the business.  Typical core business hours are Monday through Friday from 8:00am to 5:00pm.

Travel - This position may require occasional travel and attendance at local and regional/national conferences and meeti

The Perks:

• Medical / Dental / Vision / Wellness Programs
• Paid Time Off / Company Paid Holidays
• Incentive Compensation
• 401K with Company match
• Life and Disability Insurance
• Tuition Reimbursement
• Employee Referral Bonus

To explore all that MedImpact has to offer, and the greatness you can bring to our teams, please submit your resume to www.medimpact.com/careers

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.

Equal Opportunity Employer, Male/Female/Disabilities/Veterans

OSHA/ADA:

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.

Disclaimer:

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.