Pharmacy Network Compliance Associate
Who We Are:
SmithRx is a rapidly growing, venture-backed Health-Tech company. Our mission is to disrupt the expensive and inefficient Pharmacy Benefit Management (PBM) sector by building a next-generation drug acquisition platform. With hundreds of thousands of members onboarded since 2016, SmithRx has a solution that is resonating with clients all across the country.
We pride ourselves for our mission-driven and collaborative culture that inspires our employees to do their best work. We believe that the U.S healthcare system is in need of transformation, and we come to work each day dedicated to making that change a reality. At our core, we are guided by our company values of:
- Integrity: Do the right thing. Especially when it’s hard.
- Courage: Embrace the challenge.
- Together: Build bridges and lift up your colleagues.
The Pharmacy Network Compliance Associate is responsible for conducting pharmacy network audits to ensure compliance with government regulations and decrease fraud. The position documents and makes adjustments to pharmacy claims as determined by audit findings to ensure the integrity and accuracy of Smith claims data. You will develop and implement an effective compliance program to ensure the proactive identification and mitigation of compliance and regulatory risks that impede business goals and strategies. This position requires complex analytical skills and a high degree of accuracy, carrying with it high consequences of error for Smith and its clients.
What you will do:
- Assisting in the completion of license applications and/or inspection responses submissions
- Perform routine and complex audits to resolve compliance gaps while minimizing drug expense
- Management of pharmacy investigations and assist with all pharmacy complaints
- Development of pharmacy practice procedures and/or related processes to ensure regulatory compliance and operational excellence
- Ensure the compliance programs for in scope businesses are designed to meet the expectations of an effective compliance program, in accordance with applicable regulatory requirements.
- Analyze and recommend design improvements to business processes to ensure regulatory and accreditation compliance through internal policy, process, program and technical changes.
- Analyzes pharmacy profile reports for possible claim discrepancies, and fraud, waste, and abuse
- Develops tools for collecting, analyzing and synthesizing data applicable to compliance policies, procedures and systems.
- Ensures that critical issues related to pharmacy credentialing and continuing network participation are recognized, documented, and addressed according to department guidelines
- Reviews and analyzes claims data against pharmacy policy/procedures and knowledge of prescription medications to determine details of fraudulent or incorrect billing activity
- Prepares and supports the completion of pharmacy payer audits, including obtaining claim data, reviewing dispensing activities for billing errors, obtaining and reviewing requested documentation, reviewing federal/state/local pharmacy laws, documenting audit results, and coordinating the submission of audit responses to pharmacies.
- Communicates with pharmacy payers, auditors, etc. to discuss audit requests, responses, and results as needed using various media platforms (i.e. email, phone calls)
- Communicates with pharmacies to ensure claims data verification and request claim adjustments as needed which includes, but not limited to: (1) Making outbound calls to pharmacies for reprocessing and (2) Following-up with pharmacies by faxing and emailing related documents (when necessary)
- Performs follow-up inspection of claims data based on extrapolations from initial audit results
- Prepares correspondence to pharmacy providers, requesting documentation to validate detected claim discrepancies
- Prepares audit outcome documentation for pharmacies
- Develop and documents audit results
- Perform other duties as assigned
What you will bring to SmithRx:
- Bachelor’s degree or 3-5+ years’ pharmacy managed experience. Experience in Infusion, Specialty or Mail Order pharmacy is highly desired.
- Strong knowledge of the practice of pharmacy, including statutory laws, regulations, and methods of filling and filing prescriptions
- Strong Pharmacy audit experience is highly desired.
- Demonstrate process and project ownership orientation with the ability to manage a range of priorities and meet time commitments.
- Ability to effectively collaborate and communicate project status with the department team.
- Ability to work independently with minimal direction and good decision-making ability.
- Demonstrated analytical, quantitative, and organizational skills providing the ability to analyze progress, identify trends and anomalies, and recommend needed improvements.
- Solution oriented and resourceful, demonstrates excellent problem solving and customer service skills.
- Intermediate to advanced skill set in MS Office (Word, Excel, PowerPoint, and Outlook) required. Familiarity with pharmacy adjudication platforms is highly desirable. Strong aptitude to learn and adapt to new programs and systems.
What SmithRx Offers You:
- Highly competitive wellness benefits including Medical, Pharmacy, Dental, Vision, Life insurance
- Flexible Spending Benefits
- Discretionary Time Off
- 401(k) Retirement Savings Program
- Commuter Benefits
- Paid Parental Leave benefits
- Professional development and training opportunities