Pharmacy Claims Auditor

Built on meritocracy, our unique company culture rewards self-starters and those who are committed to doing what is best for our customers.

Remedy's mission is to help make prescription drugs more affordable and accessible for payors and patients for optimum health. Our analytics produce an "MRI" of a company's complex Rx spend, uncovering actionable information that saves millions of dollars, while also offering key insight into population health management. All of this can be accomplished without changing the insurer, plan design, PBM, formulary, or clinical programs.

Based in Milwaukee, WI, Remedy has a thriving business with a casual, friendly atmosphere and an entrepreneurial spirit. There are flexible work arrangements with an excellent incentive-compensation program and competitive benefits. Remedy offers an outstanding opportunity to explore, understand and impact the future of healthcare. We are a true team in every sense, and we thrive on ideas, creating new possibilities and solving challenging problems.

We are looking for a full-time experienced Pharmacy Claims Auditor with keen analytical skills and an eye for detail, to join our growing team. The Pharmacy Claims Auditor will be responsible for completing pharmacy claims audits to ensure compliance to PBM contracts. This role will involve facilitating calls with PBMs, obtaining claims audit data, perform data loading and data quality checks, data reconciliation, running and analyzing Oracle output reports, running ad-hoc analysis, reviewing PBM contracts, completing audit support documentation and working with the client support team to develop PBM & client deliverables. The Pharmacy Claims Auditor will utilize ad hoc SQL automation and build a highly customized framework to complete projects. This role will develop, prioritize, and conduct financial and operational audits to evaluate the effectiveness of PBM contracts, controls, and accuracy of financial information. This role will also take lead of the ETL process for data and will contribute to the development and enhancements of operational and business processes.

Job Responsibilities

• Plan and develop the audit approach for assigned projects consistent with guidelines established by Remedy internal Audit Standards

• Work simultaneously on multiple audits with differing deadlines while maintaining attention to detail within the appropriate timelines

• Analyze and perform quality checks of master files, profiles, and table changes to ensure all changes are appropriately accounted for

• Maintain and continuously improve upon current audit automation transforms based on audit findings, industry changes, and technology updates

• Track open audit observations and perform follow-up to evaluate the adequacy of remediation efforts with both PBM and Remedy account team

• Draft audit reports to effectively communicate the results of the analysis to Remedy account team

• Perform (daily/weekly) ad hoc data analytics requests as prioritized per Department Management

• Re-evaluate system functionality to identify opportunities for improving operational efficiencies.

• Develop the necessary tools, templates and reporting required to support any/all process improvement initiatives

• Aid in the training of new internal audit staff

• Assist in completing cross-functional projects as needed

• Comply with and adhere to all regulatory compliance areas, policies, and procedures (including HIPAA requirements), and "leading practices".

• Other Duties as Assigned

Required Qualifications

• Bachelor's degree in computer science, engineering and/or similar discipline with analytical bias

• Highly proficient in database table creation/management, ETL process, complex Oracle/SQL queries, and code maintenance

• Dimensional Model understanding and experience manipulating models, developing, and executing on business logic

• Relevant experience that demonstrates problem-solving, financial acumen, and analytical output

• Proficiency in MS Office applications (Excel, Word, Powerpoint, etc.)

• Ability to thrive in a fast-paced environment, responding quickly to oversight and following instruction closely, while anticipating needs and developing efficiencies on repeat tasks

• Excellent verbal and written communication skills to assemble data as applicable

• Experience developing and maintaining effective, collaborative working relationships with clients and internal stakeholders

• Strong sense of project ownership and the ability to manage high project volume effectively.

• Excellent problem-solving, critical thinking and analytics skills with the ability to work in a cross-functional team.

• Must be able to adapt to change in direction and priorities in a project and deadline-oriented environment.

Preferred but not required

• Experience in Project Management

• Experience with version control (git, bitbucket)

• Familiarity with Visualization tools (Tableau preferred)

• Familiarity with low code to no code solutions

• Experience working with Pharmacy and/or Medical claims data

• Pharmacy claims audit experience &/or knowledge of pharmacy claims data

Benefits

Health, Dental and Vision plans

Flexible Spending Account

Generous discretionary time-off

401(k) Retirement Savings Plan through Principal

Employee Stock Purchase Plan

We are an Equal Opportunity Employer. We take pride in the diversity of our team and seek diversity in our applicants.