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In this role, you’ll conduct pharmacy desk and/or audits, review claims and supporting documentation, identify irregularities, and help ensure compliance with policy and billing requirements. Your work will directly support fraud, waste, and abuse (FWA) detection and overall program integrity.
Job Responsibility:
Conduct pharmacy audits (desk or field) to verify accuracy of billed claims
Review prescriptions, invoices, and dispensing logs for discrepancies
Identify and document issues related to: Days’ supply, NDC accuracy, Quantity and reimbursement mismatches, Purchase vs. dispensing inconsistencies, Duplicate billing or non‑covered items
Draft clear and defensible audit findings reports
Calculate recoveries and overpayments
Collaborate with SIU, Compliance, Legal, Finance, and Provider Relations
Support escalation of potential FWA issues
Requirements:
Experience (3–5 years) in pharmacy auditing, PBM operations, or retail/clinical pharmacy with billing knowledge
Prior work with SIU or FWA investigations is a major plus
Strong command of pharmacy claims processing & PBM systems
Excel proficiency (pivots, VLOOKUPs, data comparisons)
Experience with audit management tools and reporting
CPhT strongly preferred
Bachelor’s in Pharmacy, Healthcare, Business, or related field a plus
Familiarity with NCPDP standards and third‑party billing rules
Exceptional attention to detail
Strong written communication (audit reports, summaries)
Ability to manage multiple audits simultaneously
Professional, composed communication with pharmacies and internal teams
Analytical mindset with the ability to spot trends and irregularities
Nice to have:
Prior work with SIU or FWA investigations is a major plus
Bachelor’s in Pharmacy, Healthcare, Business, or related field a plus
What we offer:
medical, vision, dental, and life and disability insurance