Location: Columbus, OH

Job Type: Full-Time and Hybrid

Department: Pharmacy Audit

Reports To: VP of Clinical Analytics

Main Purpose of Job:

Our Pharmacy Claims Auditor is responsible for performing and supporting Prescription Drug Claim Audits (claims, rebates, Medicaid/Medicare, etc.) to validate that the accuracy of drug claims, and the payment of claims to comply with the contractual obligations, regulatory requirements, and plan commitments. Using data analysis skills and tools, the Auditor will develop audit plans, manage data, create and produce reports, and present key findings and action recommendations to clients. Additionally, the Auditor will work with stakeholders on the ongoing development of audit software, protocols, and standard operating procedures.

Key Duties and Responsibilities:

• Manage and perform audits of prescription drug claim payment data to validate conformance with contractual requirements and plan specifications
• Review, evaluate, and understand client-specific documentation such as: PBM Contracts, plan design descriptions, co-pay matrices, etc.
• Evaluate the results of the initial claim data tests and determine valid audit samples for review and response by the PBM.
• Work collaboratively with PBM to resolve identified issues, review supporting documentation, and make final claim error determination.
• Ensure audit timeline is adhered to and deliver high level of service to clients.
• 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.

Required Skills, Knowledge and Attributes:

• Excellent oral and written communication skills
• Must demonstrate a high level of pharmacy benefit, claim, or benefit administration knowledge – Medicare/Medicaid benefits experience is a strong plus
• Intermediate to advanced proficiency in MS Excel (e.g., Pivot Tables, Power Query, VBA)
• Basic Proficiency in the use of business intelligence and data analysis tools, i.e., SQL, Python, and Tableau strongly preferred
• Extremely attentive to detail and can clearly and persuasively articulate the thought process in reaching conclusions and making recommendations
• Self-directed, requiring little supervision and can manage multiple projects simultaneously to ensure deadlines are met

Required Educational and Professional Background:

• Bachelor’s degree in health science, business, Accounting/Finance, or analytics discipline
• 3+ years’ experience conducting pharmacy audits strongly preferred but other deep and applicable pharmacy industry experience may be considered
• Previous PBM experience highly preferred

Interested candidates, please submit your resume for consideration to careers@hds-rx.com