Pharmacy Medical Audit Specialist at Infucare Rx Inc on behalf of itself and its subsidiaries

, , United States -

Full Time

Start Date

Immediate

Expiry Date

05 Mar, 26

Salary

0.0

Posted On

05 Dec, 25

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Medical Billing, Claims Auditing, Revenue Cycle, Payer Audits, Pharmacy Operations, Analytical Skills, Problem-Solving Skills, Attention To Detail, Communication Skills, Documentation, Compliance, Process Improvement, HIPAA, Microsoft Office, EMRs, Coding Guidelines

Industry

Hospitals and Health Care

Description

InfuCare Rx is a leading home infusion provider accredited by URAC and ACHC offering a specialized approach to caring for patients in need of IV therapy and specialty pharmacy services in the homecare setting. We have created an ethical, team-oriented, and quality work environment for our employees that cultivates achievement and success. Job Description: The Pharmacy Medical Audit Specialist is responsible for managing all medical payer audit activity, ensuring accurate and compliant medical claim submissions. This role performs detailed internal audits of medical claims, prepares and submits audit responses to medical payers, collaborates with clinical and operational teams to resolve discrepancies, and supports continuous improvement of billing, documentation, and compliance practices. This position plays a key role in safeguarding revenue integrity and ensuring compliance with payer policies, accreditation standards, and applicable state and federal regulations. General Duties: Under the direct supervision of the VP of Compliance & Accreditation, the Medical Payer Audit Specialist will be responsible for the following: * Serve as the primary point of contact for medical payer audits, including pre-payment and post-payment reviews. * Review audit requests, gather required documentation, and prepare timely, accurate, and comprehensive audit response packages. * Communicate directly with payers to clarify audit findings, dispute inaccuracies, and pursue favorable audit outcomes. * Track all audit activity, outcomes, deadlines, and financial impacts using designated audit management tools. * Support appeals for denied claims or unfavorable audit determinations. * Perform routine internal audits of medical claims to ensure accuracy, completeness, and compliance with payer requirements, medical policies, and coding/billing guidelines. * Identify billing errors, documentation gaps, and process inefficiencies; recommend corrective actions and process improvements. * Validate clinical documentation to ensure alignment with billed services, medical necessity, and regulatory requirements. * Monitor trends in audit findings and collaborate with leadership to implement preventive actions. * Ensure all claims and audit responses adhere to state and federal regulations, accreditation standards (URAC, ACHC, ACHC Specialty Pharmacy, etc.), and internal policy. * Support corrective and preventive action plans (CAPAs) for identified auditing or compliance issues. * Maintain a strong understanding of payer rules, contract requirements, coverage policies, and benefit structures. * Partner with Pharmacy, Clinical, Intake, Revenue Cycle, and Compliance teams to ensure proper claim documentation and audit readiness. * Educate internal teams on audit findings, payer policy changes, and opportunities for quality improvement. * Participate in process improvement initiatives to reduce error rates and prevent payer recoupments.  Required Education, Certification, Experience and Skill Requirements: * Associate or Bachelor’s degree in Health Information Management (HIM), Business, Healthcare Administration, or related field preferred. * Minimum of 2-4 years of prior experience in medical billing, claims auditing, revenue cycle, payer audits, or pharmacy/medical benefit operations. * Experience working with medical payers, audit responses, and document validation. * Strong understanding of medical billing guidelines (HCPCS, CPT, ICD-10), payer policies, and medical documentation requirements. * Excellent analytical and problem-solving skills with high attention to detail. * Ability to interpret complex payer policies, clinical documentation, and audit determinations. * Strong written communication skills for preparing audit responses and appeals. * Ability to manage multiple audits, deadlines, and competing priorities. * Proficiency with EMRs (CPR+, or similar), billing systems, and audit tracking tools. * Working knowledge of HIPAA, patient privacy rights, and document release protocols. * Proficiency with Microsoft Office (Word, Excel, Outlook). Preferred Qualifications: * Certified Professional Medical Auditor (CPMA) * Certified Professional Coder (CPC) * Certified Billing and Coding Specialist (CBCS) Why Join InfuCare Rx? InfuCare Rx offers a collaborative work environment, opportunities for professional growth, challenging and rewarding careers, and competitive compensation. Benefits * Medical, Dental, and Vision Insurance * Short- and Long-Term Disability * Company-Paid Life Insurance * Voluntary Life and AD&D Insurance * 401(k) with Company Match * Paid Time Off and Sick Leave * 6 Paid Holidays * Opportunities for Career Growth and Professional Development Physical Demands: Required to stand, walk, sit, talk and hear; required to use hands to operate vehicles and office equipment; must be able to occasionally lift and/or move up to 25 lbs; specific vision requirements for this job include: close, distance and peripheral vision, and the ability to adjust focus, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position without compromising patient care. InfuCare Rx is an equal opportunity employer. All employment decisions are made without regard to race, color, religion, national origin, military status, marital status, citizenship/immigration status, sex (including pregnancy and relation conditions, sexual orientation, or gender identity), age (40 and older), disability, genetic information (including employer requests for, or purchase use, or disclosure of genetic tests, genetic services, or family medical history), retaliation for filing a charge, reasonably opposing discrimination, or participating in a discrimination lawsuit, investigation, or proceeding. Background checks and drug screens are part of our hiring process. Affirmative Action/Equal Opportunity Employer, Minority/Female/Disabled/Veteran.

Responsibilities

The Pharmacy Medical Audit Specialist manages all medical payer audit activity, ensuring accurate and compliant medical claim submissions. This role includes performing internal audits, preparing audit responses, and collaborating with teams to resolve discrepancies.