MedImpact, Inc. Formulary Audit Analyst in San Diego, California
Formulary Audit Analyst
If you’re interested in a career within a customer-focused, team-oriented environment that rewards innovation, quality, integrity and collaboration, MedImpact Healthcare Systems, Inc.welcomes your application. 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.
The Formulary Audit Analyst ensures thorough research of all claims questions related to client formularies and all Part D programs handled by Formulary Services. This position has an “internal” focus and works with GPS Business Analysts and Program Managers to accomplish deliverables.
Essential Duties and Responsibilities include the following. Other duties may be assigned.
- Works closely with MedImpact’s External Compliance Support team as well as Part D Program Managers to assist clients who are undergoing audits via governmental entities (CMS), external auditing firms
- Internally facilitates research and responses to claim questions or audit findings; influences formulary management decisions and audit outcomes by providing researched data as well as the basis and support for MedImpact’s position
- Collaborates closely with cross functional team members in the Government Programs and Services, Prior Authorization, POS Operations team, Regulatory Compliance
- Communicates as needed to external governmental auditors, MedImpact’s clients, financial auditing firms and Plan Sponsors
- Maintains and augments personal knowledge related to changes in state and federal laws including but not limited to CMS guidance, Medicare and Medicaid rules and regulations related to and affecting formulary audits and practices
- Understands and keeps current with those State and Federal rules as well as how MedImpact implements those rules
- Applies CMS rules to MedImpact’s practices
- Handles a large volume of formulary audit and formulary PBM oversight support requests through a CRM (Salesforce)
- Researches MedImpact’s historical handling of scenarios by reviewing claims data, adjudication logic, calculations as well as consulting internal subject matter experts (SMEs)
- Works with Business Analysts to define query parameters (or universes) for data related to claims adjudication, financial calculations, reporting rules, etc. to understand and formulate responses to external entities
- Shares with other staff of new client developments and provides the necessary training for issue resolution, pulling data and running queries, audit changes State and Federal Regulations and PBM Oversight obligations
- Explains to a variety of internal audiences claims adjudication rules, technical configuration, the “why” behind CMS rules
- Pulls data and runs queries to support audits and to educate others on processes
- Responsible for the completion of assigned projects including claims adjudication analysis, Formulary PBM Oversight report package delivery to clients to achieve audit and service commitments
- Initiates attendance at seminars and industry meetings to keep current with best practices, regulations and industry guidance
*Education and/or Experience *
For consideration, candidates will need a Bachelor’s degree in a related field (or equivalent combination of education and job related experience); a minimum of two (2) to five (5) years’ experience in retail pharmacy. Candidates must have knowledge of Part D claims processing along with at least one (1) to two (2) years’ of medical claims adjudication and/ or knowledge of pharmacy claims processing. Prior experience in the healthcare field, PBM or closely related industry is required. Medicare Part D experience is a plus.
- Intermediate skill set in MS Office (Word, Excel, and Outlook) required
- Familiarity with relational database systems
- Strong aptitude to learn and adapt to new programs
Certificates, Licenses, Registrations
Current Pharmacy Technician License and/or CPhT certification without restriction preferred
*Other Skills and Abilities *
- Knowledge of pharmacy claims and claims processing desired
- Knowledge of medications and standard dosages
- Strong knowledge of the practice of pharmacy, including statutory laws, regulations, and methods of filling and filing prescriptions
- Thorough understanding of Drug Utilization Review (max dose, days supply, etc.) principles
- Ability to work independently with minimal direction and strong decision-making ability
- Strong organizational and follow-through skills
- Strong interpersonal and oral and written communication skills with the ability to maintain tact and diplomacy in difficult situations
- This position requires technically complex analysis and a high degree of accuracy, carrying with it high consequence of error for MedImpact and its customers
- It relies upon business knowledge, including industry concepts and practices, technical skills, and prior experience to plan and accomplish goals
This position is eligible for Employee Referral Bonus at Level I
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.
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.
Location: San Diego, CA
# of openings: 1
Employment duration: Full time
Relocation Assistance: N/A
Job Code: 410.180417.5464