Location: This position will work a hybrid model (remote and office). Ideal candidates will live within 50 miles of one of our PulsePoint locations.
A proud member of the Elevance Health family of companies, CarelonRx leverages the power of new technologies and a strong, clinical-first lens, to deliver member-centered, lasting pharmacy care.
The Pharmacy Internal Auditor is responsible for driving service quality excellence by evaluating the quality of services and interactions provided by CarleonRx pharmacies. Included are all pharmacy processes and processes related to enrollment and billing and claims processing, as well as customer service written and verbal inquiries.
How you will make an impact:
Assists higher level auditor/lead on field work as assigned and acts as auditor in charge on small and less complex audits.
Participates in pre and post implementation audits of pharmacy operational processes, claims processing and payment, member and provider inquiries, enrollment & billing transactions, and the corrective action plan process.
Demonstrates ability to audit multiple lines of business, multiple functions, and multiple systems.
Analyzes and interprets data and makes recommendations for change based on judgment and experience, applies audit policy, and assesses risks to minimize our exposure and mitigate those risks.
Works closely with the business to provide consultation and advice to management related to policy and procedure identified as out of date or incomplete and investigates, develops, and recommends process improvements and solutions.
Functions as a subject matter expert for discrepancy review, questions from team and business partners, and interpretation of guidelines and audit process.
Acts as a mentor to peer auditors, providing training and managing work and projects as necessary.
Travel to sites to oversee the implementation and follow up of new and enhanced processes and programs; or to perform audits.
Minimum Requirements:
Requires a BS/BA; a minimum of 3 years related experience in an enrollment and billing, claims and/or customer contact automated environment (preferably in healthcare or insurance sector), including a minimum of 1-year related experience in a quality audit capacity; or any combination of education and experience, which would provide an equivalent background.
Preferred Skills, Capabilities and Experiences:
Experience in a high volume, mail order, or specialty pharmacy preferred.
Ability to work independently and as part of a team.
Demonstrated experience netting improvements from audits.
