Prior Authorization Audit Specialist I

Exemption Status:United States of America (Non-Exempt)

$45,984 - $60,699 - $75,415

“Pay scale information is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any selected candidate or employee, which is always dependent on actual experience, education, qualifications, and other factors.  A full review of our comprehensive pay and benefits will be discussed at the offer stage with the selected candidate.”

This position is not eligible for Sponsorship.

MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team!

Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare.

At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution!

Job Description

The Prior Authorization Audit Specialist I assess the quality of Clinical Prior Authorizations being processed by pharmacy technicians and data entry clerks.  This position advises management of quality assurance audit results, performance issues, and training issues and works under general supervision, relying upon pre-defined Best Practices audit criteria , work process guidelines, policies & procedures, and company knowledge/experience to perform the functions of the job.  The extent of supervision ranges from close to moderate based upon demonstrated skill and performance levels as defined for the position.

The Prior Authorization Audit Specialist I conducts front to end prior authorization case reviews for PA coordinators, data entry clerks, clinical reviewers, and vendor PACs in accordance with standards for accuracy (NCQA accreditation), timeliness (state and federal requirements), productivity, and client performance guarantees (PGs).  The PA Audit Specialist I develops, builds, and maintains solid staff relationships beginning with a positive on-boarding experience beginning with the Case Review Audit Criteria (CRAC) orientation and continuing throughout their employment in accordance with adherence to MedImpact processes and policies, quality, and new implementations.  This position partners with various departments to report untimely Part D PAs, Appeals and DMRs as required per CMS regulations, tracks the untimely case in the applicable tracking program and communicates untimely cases/decisions to the client team. 

Essential Functions and Responsibilities include the following. Other duties may be assigned.

• Conducts a required number of internal audits of PA staff’s work to ensure compliance with MedImpact’ s pre-defined audit criteria, policies and procedures including state or regulatory requirements such as NCQA and UR Licensure requirements
• Perform a minimum number of audits of PA staff’s  work to ensure accurate and timely information is administered, documented and provided
• Audit Technical Call Center for Quality Assurance measurements
•  Identify and make recommendations to department leadership for improvement of workflow    processes, system enhancements, training programs, reference materials, and quality initiatives
• Provide feedback to staff regarding individual audit results and provide training as deemed necessary
• Generates SQL/MedOptimize queries to report client specific data and PART-D status to management
• Generates SQL queries to report client specific data and PART D status to management
• Compile detailed audit reports summarizing audit results for monthly staff performance ratings, performance guarantee tracking and compliance oversight.
• Provide coaching and feedback to staff  regarding their audit results and provide training as needed
• Client facing subject matter expert regarding PART D PA processing and timeliness
• Keep current on new plan information and instructions by attending and participating in staff meetings
• Responsible for authoring monthly Required Training Lessons (RTL’s) for the PAC’s and Data Entry Clerks and posting the RTL’s in TMS via Storyline3 software
• Lead/attend WebX meetings with both internal/external clients
• Ensures Performance Guarantee deliverables are achieved by performing monthly or quarterly audits as requested by clients.
• Understands interdepartmental processes as they affect the Prior Authorization, Appeals, Claims and PA Audit Team.
• Responsible for responding to untimely PART-D notifications, compiling and Auto-Forwarding  untimely Coverage Determinations, Redeterminations (Appeals) & Direct Member Reimbursements (DMR) PART-D cases to IRE via the CMS portal (includes MedResponse & MedResponse Appeals documentation and SalesForce tracking)  This includes an on-call rotation on weekends to monitor and report untimely PART D cases identified after hours.
• Effectuation of overturned cases rendered by external review entities such as Maximus/IRE, Administrative Law Jude (ALJ), Medicare Administrative Contractor (MAC) or Judicial Review.
• Provides assistance to PA Operations with PA processing or Data Entry as needed. (e.g., during
• Assists with development and maintenance of staff audit criteria.
• Stays current with and applies CMS requirements for Medicare Part D internal Prior Authorizations.

Education and/or Experience

Associate's degree (A.A.) or equivalent from two-year College or technical school; or 1-3 years of related experience and/or training; or equivalent combination of education and experience.  PBM, Health Plan, or Health Care background preferred.

Bachelor’s or Associate’s degree and 2 years of direct experience and/or training; or equivalent combination of education and experience. Prior PBM, healthcare, or managed care experience preferred.

Computer Skills

Experience writing SQL queries and/or MedOptimize experience is preferred.  Articulate 360 experience preferred.  MedAccess & MedResponse experience is preferred.  Experience with Windows based database programs is required. This role utilizes multiple programs such as MedAccess Classic and Web, SalesForce, MedResponse, SQL, MedResponse Appeals, MedOptimize and Formulary Analyzer to perform auditing functions.

Certifications, Licenses, Registrations

Must successfully complete one of the national certification exams OR obtain state licensure (in an U.S. State or Territory). Maintains a current Pharmacy Technician License and/or CPhT Certification without restriction.

The Perks:

• Medical / Dental / Vision / Wellness Programs
• Paid Time Off / Company Paid Holidays
• Incentive Compensation
• 401K with Company match
• Life and Disability Insurance
• Tuition Reimbursement
• Employee Referral Bonus

To explore all that MedImpact has to offer, and the greatness you can bring to our teams, please submit your resume to www.medimpact.com/careers

MedImpact, is a privately-held pharmacy benefit manager (PBM) headquartered in San Diego,
California. Our solutions and services positively influence healthcare outcomes and expenditures, improving the position of our clients in the market. MedImpact offers high-value solutions to payers, providers and consumers of healthcare in the U.S. and foreign markets.

Equal Opportunity Employer, Male/Female/Disabilities/VeteransOSHA/ADA:

To perform this job successfully, the successful candidate must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Disclaimer:

The above
statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.