- Analytical and operational understanding of Navitus' reimbursement programs including AWP, WAC, MAC, NADAC, FUL, AAC, Average Dispensing Fee, and other pricing structures.
- Responsible for fielding, analyzing, and resolving inquiries from pharmacy providers, clients, auditors, and internal teams regarding Retail, Specialty, and Mail Order pricing errors with focus on the root cause.
- Interpret pharmacy contract language to compare Retail, Specialty, and Mail Order contract pricing to adjudicated claims activity.
- Continuously review and pro-actively identify areas of opportunity for reimbursement compliance for both providers and clients, including analysis and communication of activities.
- Develop and maintain appropriate controls and oversight reporting on the end-to-end process of Retail, Specialty, and Mail Order contract pricing. If process controls are absent, the expectation is to identify, define, and implement new processes as needed.
- Responsible for pharmacy network rate testing, chain audits, analysis, and impact assessment.
- Make decisions regarding the resolution of pharmacy network pricing setup issues.
- Submit service requests, recovery requests, and/or engage applicable teams to make system updates/changes.
- Periodic and detailed reporting of contractual compliance activities and opportunities to Provider Services team and cross-functional leadership.
- Identify, advocate, and implement continual process improvement of policies and procedures to maximize quality and efficiencies.
- Bachelor's degree or equivalent experience required. Emphasis in business, finance, economics, or operations preferred
- Minimum two years analytics experience required
- Participate in, adhere to, and support compliance program objectives
- The ability to consistently interact cooperatively and respectfully with other employees
- Hours/Location: Monday-Friday 8:00am-5:30pm CST, Remote or Hybrid in our Madison WI, Appleton WI or Austin TX Office
- Paid Volunteer Hours
- Educational Assistance Plan and Professional Membership assistance
- Referral Bonus Program – up to $750
- Top of the industry benefits for Health, Dental, and Vision insurance, Flexible Spending Account, Paid Time Off, Nine paid holidays, 401K, Short-term and Long-term disability, College Savings Plan, Paid Parental Leave, Adoption Assistance Program, and Employee Assistance Program
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Analyst, Pharmacy Audit-Remote - Austin, United States - Navitus
Description
Putting People First in Pharmacy- Navitus was founded as an alternative to traditional pharmacy benefit manager (PBM) models. We are committed to removing cost from the drug supply chain to make medications more affordable for the people who need them. At Navitus, our team members work in an environment that celebrates diversity, fosters creativity and encourages growth. We welcome new ideas and share a passion for excellent service to our customers and each other.
Due to growth, we are adding this Analyst, Pharmacy Audit to our Provider Services department.
We are unable to offer remote work to residents of Alaska, Hawaii, Maine, Mississippi, New Hampshire, New Mexico, North Dakota, Rhode Island, South Carolina, South Dakota, West Virginia, and Wyoming.
The Analyst, Pharmacy Audit is responsible for the oversight of Navitus' contractual pharmacy network reimbursement accuracy. The individual in this position is expected to make independent assessments to confirm Navitus is conforming to contractual reimbursement obligations contained in Retail, Specialty, and Mail Order pharmacy agreements. The Analyst will continually review and monitor claims data, create, and update procedures, audit networks for price change accuracy, monitor compliance with Navitus pharmacy provider contracts, communicate findings, and work with applicable teams to remediate errors.
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