Pharmacy Contract Audit Analyst
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Job Description
Pharmacy contract audit analyst validating Retail, Specialty, and Mail Order reimbursement accuracy for Navitus, a pharmacy benefit manager. Monitoring claims, auditing networks, and resolving contractual pricing issues.
Responsibilities:
- Oversee Navitus’ contractual pharmacy network reimbursement accuracy
- Independently assess compliance with contractual reimbursement obligations in Retail, Specialty, and Mail Order pharmacy agreements
- Review and monitor claims data
- Create and update procedures
- Audit networks for price change accuracy
- Monitor compliance with pharmacy provider contracts
- Communicate findings and work with applicable teams to remediate errors
- Interpret contractual terms, client network selections, and their operationalization in applicable systems
- Utilize Navitus’ adjudication system (NCRx) and contracting and credentialing databases (PC2), among other applications
- Analyze provider, client, and network performance for network development, quality control, and contractual compliance
- Create reports validating systems accuracy against Retail, Specialty, and Mail Order contractual terms
- Field, analyze, and resolve pricing-error inquiries from pharmacy providers, clients, auditors, and internal teams, focusing on root cause
- Develop and maintain controls and oversight reporting for contract pricing
- Identify, define, and implement new processes when controls are absent
- Conduct pharmacy network rate testing, chain audits, and impact assessments
- Submit service requests and recovery requests and engage applicable teams for system updates or changes
- Report contractual compliance activities and opportunities to the Provider Services team and cross-functional leadership
- Perform other duties as assigned
Requirements:
- Bachelor’s degree or equivalent experience required
- Emphasis in business, finance, economics, or operations preferred
- Minimum two years analytics experience required
- Analytical and operational understanding of Navitus’ reimbursement programs including AWP, WAC, MAC, NADAC, FUL, AAC, Average Dispensing Fee, and other pricing structures
- Ability to interpret pharmacy contract language and compare contract pricing to adjudicated claims activity
- Ability to develop and maintain controls and oversight reporting
- Ability to perform pharmacy network rate testing, chain audits, analysis, and impact assessment
- Ability to make decisions regarding pharmacy network pricing setup issues
- Ability to understand, follow, and improve operational and administrative processes
- Ability to participate in, adhere to, and support compliance program objectives
- Ability to consistently interact cooperatively and respectfully with other employees
- Ability to work remotely from an eligible US state; remote work unavailable to residents of Alaska, Hawaii, Maine, Mississippi, New Hampshire, New Mexico, North Dakota, Rhode Island, South Carolina, South Dakota, West Virginia, and Wyoming
Benefits:
- Top of the industry benefits for Health, Dental, and Vision insurance
- 20 days paid time off
- 4 weeks paid parental leave
- 9 paid holidays
- 401K company match of up to 5% - No vesting requirement
- Adoption Assistance Program
- Flexible Spending Account
- Educational Assistance Plan and Professional Membership assistance
- Referral Bonus Program – up to $750!
- M-F 8:00am-5:00pm schedule
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