Pharmacy Audit Specialist

• 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.
• Support appeals for denied claims or unfavorable audit determinations.
• Review dispensed pharmacy and medical claims and adjudication to ensure claims are billed appropriately and in accordance with payer requirements, plan policies, and coding/billing guidelines (HCPCS, CPT, ICD-10).
• Validate clinical documentation to ensure alignment with billed services, medical necessity, and regulatory requirements.
• Maintain a strong working knowledge of payer rules, contract requirements, coverage policies, and benefit structures.

• Serve as a key point of contact for incoming medical records requests from payers, auditors, and other authorized entities.
• Gather, review, and compile requested medical records and supporting documentation accurately and within required deadlines.
• Ensure all medical records releases comply with HIPAA, patient privacy rights, and company document release protocols.
• Track and log medical records requests and responses, escalating incomplete documentation or missed deadlines as needed.
• Coordinate with Clinical, Intake, and Revenue Cycle teams to obtain supporting documentation needed for record production and audit readiness.

• Perform routine internal audits of operations to ensure compliance with company policies and procedures, accreditation standards, and federal and state regulations. Identify errors, documentation gaps, and process inefficiencies; recommend and support corrective action plans and process improvements.
• Assess situations to determine corrective action plans in conjunction with, and under the guidance of, the Manager.
• Support corrective and preventive action plans (CAPAs) for identified auditing or compliance issues.
• Prepare clear, well-supported audit findings and reports for leadership, providing sufficient detail to defend conclusions if challenged by a payer, regulator, or accrediting body.
• Track and analyze audit findings over time to identify recurring or systemic issues, rather than addressing errors in isolation.
• Safeguard confidentiality of protected health information (PHI) and other sensitive records accessed during the course of audits, in accordance with HIPAA and company policy.
• Monitor updates to applicable laws, payer requirements, and accreditation standards (e.g., URAC, ACHC) to ensure audit criteria and processes remain current.
• Follow up on corrective and preventive action plans (CAPAs) to verify that corrective actions were implemented and effective, closing the loop on identified issues.
• Collaborate with compliance, pharmacy operations, and billing/claims teams to align audit findings with broader organizational compliance efforts.
• Escalate significant findings — such as suspected fraud, diversion, or patient safety concerns — to appropriate leadership or compliance channels per established escalation procedures.

• 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.
• Assist the Compliance & Accreditation team with other duties as needed.
• Actively participate in internal quality improvement teams and initiatives in accordance with the mission and strategic goals of the organization, applicable laws and regulations, and accreditation standards, when assigned.

• Align actions to actively support company goals and objectives while working within organizational protocols, company policies, and regulatory requirements.
• Adhere to appropriate safety and quality assurance practices.
• Educate themselves on the scope of services available through the company; understand basic drug terminology and therapies/services provided.
• Present a professional appearance and approach and demonstrate honest and ethical behavior.
• Handle company information with appropriate sensitivity and safeguards to ensure confidentiality and right to privacy, in compliance with applicable local, state, and federal laws.
• Contribute to the effectiveness of the team by supporting, promoting, and applying best-practice standards of conduct, including attendance, mutual respect and support, honoring diversity, effective communication, and improving the work environment.
• Exhibit flexibility when work assignments need to be adjusted to meet service delivery and workload needs of the team.
• Take initiative to identify, develop, and adopt new policies and practices that improve quality of work.
• Understand and comply with the healthcare regulatory environment and applicable local, state, and federal laws.

Required Education, Certification, Experience & Skills

• Associate's or Bachelor's degree in Health Information Management (HIM), Business, Healthcare Administration, or a related field preferred; equivalent experience considered.
• Minimum of three to five (3–5) years of experience in pharmacy operations, pharmacy audits, medical billing/claims auditing, revenue cycle, payer audits, or pharmacy/medical benefit operations.
• Strong pharmacy background with experience in claim adjudication and billing.
• Experience working directly with medical payers, preparing audit responses, and performing document validation.
• Strong understanding of medical billing guidelines (HCPCS, CPT, ICD-10), payer policies, and medical documentation requirements.
• Ability to interpret complex payer policies, clinical documentation, and audit determinations.
• Assesses situations to determine corrective action plans or actions needed for resolution in conjunction with and under the guidance of the Manager.
• Able to work under pressure, manage multiple audits and competing priorities, and meet deadlines.
• Timeline-oriented with a proven record of confidentiality and discretion with critical information.
• Able to identify and resolve issues quickly and efficiently; works independently as needed while also functioning effectively within a team environment.
• Excellent verbal and written communication skills, including preparing audit responses and appeals; strong problem-solving and organizational skills with attention to detail, accuracy, and follow-through.
• Strong customer service and interpersonal skills with internal and external customers.
• Proficiency with EMRs (CPR+ or similar), billing systems, and audit tracking tools.
• Proficiency in Microsoft Office (Word, Excel, Outlook).
• Working knowledge of HIPAA, patient privacy rights, and medical records/document release protocols.
• Familiarity with ACHC, URAC, and other healthcare provider accreditation bodies.
• Pharmacy technician license; active and in good standing.

• National Pharmacy Technician Certification.
• Certified Professional Medical Auditor (CPMA).
• Certified Professional Coder (CPC).
• Certified Billing and Coding Specialist (CBCS).