External Job Posting
Evaluates and mitigates third party pharmacy audits and recoupment. Analyzes root cause and works with pharmacies, prescribers, recovery services and third party payers to achieve favorable audit results. Maintains audit reporting to include audit stages and at risk and final audit findings.
DUTIES & RESPONSIBILITIES:
• Identifies key root causes of Audits and work to reduce by educating the organization.
• Ensures that the audit documentation is complete by gathering the appropriate documentation. Also responsible for verifying the accuracy of any file documentation submitted by pharmacies for appropriate claims.
• Works with prescriber’s offices to gather appropriate medical records for audits and verify accuracy when applicable.
• Assembles and submit audits to Medicare Part B and other Third Party payers
• Documents and tracks requests and results in Excel or other Third Party applications.
• Reports on Total Risk, Preliminary Findings, and Final Recoupment.
• Engages with Third Party Plans Auditors building relationships, challenging findings, and improving overall Audit Scores.
• Maintains an understanding of Third Party Plan / ShopKo contractual terms related to Audits and work with VP of Managed Care to maintain repository file of language.
Pharmacy Claim Education
• Ensures pharmacy teams are following proper Medicare Documentation Procedures. Work with pharmacy teams who are falling short of Shopko standards
• Drafts regular “Audit Tips” for weekly communication to pharmacies
• Works with prescribers to educate them on necessary documentation requirements
• Develops new audit documentation policies and procedures and offer insights to improve current policies and procedures. Work with the appropriate teams to implement updated policies and procedures.
• Assists with updating Medicare compliance materials as regulations or audit focus changes
MINIMUM KNOWLEDGE, EXPERIENCE & SKILLS REQUIREMENTS:
• High School Diploma
• 2+ Years Health Services Pharmacy Experience
• 2+ Years’ experience working with third party claims adjudication – particularly Medicare B
• Exceptional attention to detail and organizational skills
• Ability to communicate professionally and appropriately with internal and external parties
• Excellent oral and written communication skills
• Strong understanding of Microsoft Excel, and Word document.
We provide general merchandise, Pharmacy, and Optical services in our store formats of Shopko, Shopko Hometown, and Shopko Express.
At Shopko, we understand what matters to our customers. Our stores are designed to be simple, clean, and welcoming, not overwhelming. We offer the essentials our customers need and the brands they trust at a fair price. Shopko, the Stuff that counts.
Shopko offers a professional team-oriented work environment, career advancement opportunities, competitive wages, and a comprehensive benefits package! If you are accessing this posting from another website, please submit an application at www.shopko.com/careers.
Shopko is an Equal Opportunity Employer functioning under an Affirmative Action Plan m/f/d/v.