Pharmacy Credentialing & Audit Analyst - AZ Residents Only

at  CVS Health

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POSITION SUMMARY

The Pharmacy Quality Control Analyst position is responsible for the timely and accurate delivery of key department, company, and client driven deliverables. The primary areas of responsibility include standards conformance, audit sampling, and regulatory compliance support. This position is accountable for and performs an integral role in the enforcement and administration of quality control compliance for pharmacy provider enrollment; pharmacy provider credentialing and contract audit sampling fulfillment; and legal-regulatory requests for pharmacy contracting information. Duties of the Analyst require a high degree of critical independent thinking, a keen sense of judgement with the ability to make decisions efficiently. Day to day functions require a strong focus with mental endurance and the flexibility to adapt to a fast-paced work environment with limited supervision. The Analyst must possess the sustainability and aptitude to create new tools and reports while maintaining an in depth understanding of the PBM and enterprise pharmacy environment. The Analyst interfaces with and manages communication with a multi-level audience.

REQUIRED QUALIFICATIONS

• 4 years experience with credentialing and/ or auditing within a pharmacy/ medical setting.
• Must reside in Arizona
• Strong knowledge of mainframe applications for pharmacy enrollment and claims processing for (Recap &, RxClaim)
• Proficient in Microsoft Office - Excel, Word, and Access. Ability to perform detailed QC functions in a speedy, efficient, and accurate manner is critical.

PREFERRED QUALIFICATIONS

• Adobe
• Strong interpersonal skills, written and verbal communication skills
• Ability to work independently and as a team, manage large workload, multiple deliverables, and projects simultaneously.
• Bachelor’s Degree
  Education
  High School Diploma or equivalent GED

Quality Control Pharmacy Provider Network - This position is responsible for ensuring pharmacy enrollment compliance with respect to SOX internal controls, SSAE-16 (SOC1) Reporting, and URAC accreditation. This position is accountable for the detection and prevention of pharmacy enrollment errors and omissions. Functions of this role include validation and verification of documentation compliance and data accuracy of pharmacy enrollment to mitigate negative financial business impacts and avoid service warranties, client issued corrective action plans, and to promote successful pharmacy network enrollment audits. Ongoing value-added activities center around continual development and enhancement of the quality review processes and tools for increased control and efficiency; SME support and analysis for ad hoc projects; interface with internal partners and lead cross functional task groups.
Pharmacy Provider Credentialing & Contract Audit fulfillment – responsible for the assessment and compilation of audit sampling documentation. This includes accountability for the accurate interpretation of the audit scope and requirements which is critical to safeguard confidential and proprietary documents, prevent inclusion of ancillary non- value- added documentation, ensure audit requirements are in compliance with company policy and avoid client issued corrective action plan.
Legal & Regulatory Requests for Information (RFI’s) related to Pharmacy Credentialing & Contracting – accountable for the accurate assessment and scrutiny of the request to ensure that the correct documentation is supplied. Accurate interpretation of the request and the ability to assess the business need are critical to avoid documentation errors or omissions for litigation, or regulatory investigations (e.g. FBI, Federal & State OIG/OAG, DOH, MEDIC, etc.).