Pharmacy Claims Compliance Specialist

6 days ago

Cebu City, Central Visayas, Philippines KMC Solutions Full time ₱900,000 - ₱1,200,000 per year

Job Overview:

  • Work on-site at our Cebu office
  • Night shift
  • Pharmacy degree (Pharm. D.) or equivalent; and 2+ years related retail experience and/or training; or equivalent combination of education and experience.

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

  • Prepares and completes retrospective desktop, and targeted audits, including obtaining claim data for analysis, reviewing dispensing activities for billing errors, reviewing federal/state/local pharmacy laws, documenting audit results, notifying pharmacies, and preparing audit plans, and schedules as appropriate.
  • Responsible for providing clinical support services to department and to client plan(s) contracting for audit services. Support services will include, but not limited to, clinical review, data query recommendations, and audited claims review; particularly those reviews requiring clinical expertise (e.g., compound and specialty claims).
  • Review audit guidelines and algorithms for clinical appropriateness and operational efficiency. Assist in the revision and creation of new or existing audit guidelines and algorithms as indicated.
  • Provide drug information support. Research and provide clinical documentation to support reporting and algorithm needs as indicated. May include recommendations for audit criteria based on known or suspected drug schemes including diversion, doctor, and pharmacy shopping, etc.
  • Coordinate and assist in the preparation of utilization and audit reporting for client plans based on fraud, waste and abuse reports and data queries. Ensure timely preparation and review of claims data and client reports, when required.
  • Coordinate and assist with projects to identify, analyze, and report on new fraud schemes that may impact the clients.

Qualifications:

  • Pharmacy degree (Pharm. D.) or equivalent; and 2+ years related retail experience and/or training; or equivalent combination of education and experience.
  • Intermediate to advanced skill set in MS Office (Word, Excel, PowerPoint, Project, and Outlook) required. Familiarity with relational database systems and SQL software front ends such as Cognos highly desirable. Intermediate to advanced skill set in MedAccess, and SalesForce preferred. Strong aptitude to learn and adapt to new programs.
  • Registered Pharmacist license is a plus
  • Excellent working knowledge of all types of pharmacy services with an emphasis on the managed health care environment. Expertise in clinical application of pharmacy practices

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