Pharmacy Process Audit Technician

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San Diego, CA
$65,000 - $66,000
Job Type
Direct Hire
Aug 21, 2017
Job ID
Progressive Health Plan located in San Diego CA is currently recruiting for a full-time Pharmacy Process Audit Technician.  This position offers opportunities for personal and professional growth.

Position Description

The Pharmacy Process/Audit Tech conducts oversight and audit of Pharmacy department and PBM activities to ensure compliance with a department policies and procedures as well as state and federal regulations.  They will validate accuracy, completeness and timeliness for all commercial and Medicare pharmacy processes, including but not limited to formulary file postings, website postings, claims adjudication, and member and provider letters.  Completes daily denied claims review for all lines of business and conducts calls to members, pharmacies and provider offices to facilitate member access to care.  Processes member reimbursement requests and supports Prior Authorization review when needed.

  • Bachelor’s degree in business or health care related field required
  • Ability to function independently and manage a variety of project simultaneously.
  • Ability to manage tight deadlines and multiple priorities.
  • Excellent knowledge of medical terminology, especially terms used in pharmacy practice, trade/generic drug names, drug pricing interpretation, metric system, CMS Part D regulations and requirements and CMS RXCUI nomenclature, state and federal pharmacy regulations.
  • Excellent computer skills in Internet and PC based software application, including word processing, manipulation of complex databases, Excel spreadsheets and pivot tables, and project management software.
  • Effective interpersonal skills, excellent oral and written communications skills.
  • Experience and success with interacting with senior level positions, both internally and externally.
  • Ability to analyze data and other written and verbal information.
  • Ability to synopsize and produce recommendations to managers succinctly yet thoroughly.
  • Experience in position requires high levels of cooperation, collaboration, analysis, troubleshooting, and problem resolution.  
  • Research skills and experience producing executive summaries, presentation, proposals, and recommendations. 
  • Demonstrated experience in writing and editing of varied communication materials.
  • Previous health plan/PBM experience preferred
  • Previous experience with Medicare Part D programs preferred
Ideal Candidate

We are looking for a bachelors prepared data analyst with experience working with large databases (Excel or Access) and have Medicare Part D experience.  This person should enjoy working with data sources  (analyzing, manipulating, summarizing, and finding trends).