Job Description

Location: Hybrid (Local to NYC, Denver or Charlotte areas)

The Pharmacy Auditor is responsible for conducting comprehensive audits of network pharmacies to ensure compliance with contractual obligations, regulatory requirements, client expectations, and industry standards. This role evaluates the accuracy of pharmacy claims, prescription dispensing practices, inventory records, and supporting documentation to identify billing discrepancies, recover overpayments, and promote program integrity.

The Pharmacy Auditor plays a critical role in safeguarding healthcare resources by identifying operational, billing, and compliance risks within the pharmacy network. This position collaborates closely with Compliance, Legal, Finance, Provider Relations, Clinical, and Fraud, Waste, and Abuse (FWA) teams to support corrective actions, recoveries, regulatory requirements, and education initiatives.

Position Responsibilities:

• Conduct desk, remote, and on-site pharmacy audits to evaluate pharmacy compliance with contractual, regulatory, and operational requirements.
• Review prescription records, claims data, purchase invoices, inventory documentation, dispensing logs, and other supporting records to validate the accuracy and legitimacy of billed claims.
• Analyze pharmacy claims and utilization data to identify potential discrepancies, billing irregularities, overpayments, and areas of non-compliance.
• Calculate and document audit findings and financial recoveries in accordance with established audit methodologies, client requirements, and applicable laws and regulations.
• Prepare clear, accurate, and comprehensive audit reports outlining findings, root causes, financial impact, and recommended corrective actions.
• Communicate audit observations, findings, and recovery determinations to pharmacies and internal stakeholders in a professional and effective manner.
• Monitor corrective action plans and follow-up activities to ensure resolution of identified deficiencies.
• Collaborate with Special Investigations Unit personnel when audit findings indicate potential fraud, waste, or abuse concerns requiring further review.
• Support regulatory examinations, client audits, grievance investigations, appeals, and special projects as assigned.
• Maintain thorough documentation in accordance with audit standards, organizational policies, and record retention requirements.
• Stay current on applicable federal and state pharmacy regulations, CMS requirements, NCPDP standards, PBM policies, and industry best practices.
• Participate in the development and enhancement of audit methodologies, policies, procedures, and reporting processes.
• Assist with training and education initiatives for internal teams and network pharmacies regarding audit findings and compliance expectations.

Required Qualifications

Education:

• Bachelor's degree in Healthcare Administration, Business Administration, Pharmacy, Accounting, Finance, or a related field preferred.
• Certified Pharmacy Technician (CPhT) designation strongly preferred.
• Additional certifications related to auditing, compliance, healthcare fraud investigation, or pharmacy operations are a plus.

Experience:

• Two (2) to five (5) years of experience in pharmacy auditing, PBM operations, pharmacy compliance, healthcare auditing, pharmacy practice, or a related field required.
• Experience reviewing pharmacy claims, prescription documentation, inventory records, and third-party billing processes preferred.
• Working knowledge of pharmacy benefit management operations, Medicare, Medicaid, and commercial pharmacy benefit programs preferred.
• Experience utilizing audit, reporting, and data analytics tools to identify trends, anomalies, and recovery opportunities preferred.

Knowledge, Skills, and Abilities

• Strong analytical, investigative, and problem-solving skills with the ability to identify complex billing and compliance issues.
• Exceptional attention to detail and accuracy in reviewing documentation and preparing audit reports.
• Ability to interpret contracts, policies, regulations, and audit standards.
• Strong written and verbal communication skills with the ability to effectively present findings to both internal and external stakeholders.
• Excellent organizational and time-management skills, including the ability to manage multiple audits and competing priorities simultaneously.
• Proficiency in Microsoft Office Suite, particularly Excel, Word, PowerPoint, and data analysis tools.
• Ability to maintain confidentiality and exercise sound professional judgment when handling sensitive information.
• Demonstrated ability to work independently while collaborating effectively within a cross-functional team environment.

Physical and Travel Requirements

• Ability to travel periodically for on-site pharmacy audits and business-related meetings, as needed.
• Ability to work in a hybrid environment and perform work primarily using standard office technology and equipment.