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Claims Management - Quality & Audit Advocate

Virtual Req #644
Wednesday, October 13, 2021

Our goals are to provide excellent service, utilize advanced technology, and proficiently deliver results. To accomplish these goals, we constantly seek individuals who look for ways to do things better. We are a company whose culture cultivates teamwork, rewards excellence, focuses on quality for every aspect of our business, and promotes community involvement.
 

Tabula Rasa HealthCare (TRHC) is a leader in providing patient-specific, data-driven technology and solutions that enable healthcare organizations to optimize performance to improve patient outcomes, reduce hospitalizations, lower healthcare costs, and manage risk. Medication risk management is TRHC’s lead offering, and its cloud-based software applications, including EireneRx® and MedWise™, provide solutions for a range of payers, providers and other healthcare organizations.

 

TRHC empowers our employees to provide excellent service, utilize advanced technology, and proficiently deliver results. Our 32Fundamentals are what we are and who we are.  Our culture cultivates teamwork, rewards excellence, focuses on quality for every aspect of our business, and promotes community involvement. As a part of our team, you will help us bring innovative service models to healthcare, improving patient outcomes.

Summary

Under the supervision of the Manager of Quality and Audit, the Quality and Audit Advocate is responsible for working closely with the Quality and Audit team to ensure Pharmastar’s adherence to both internal and regulatory procedures, ensure proper documentation, provide reporting activities, and disseminate applicable information to clients.

 

This position also assists with various internal tasks that ensure a high level of overall client satisfaction. On the job training will be provided.

 

Pharmastar (a Tabula Rasa HealthCare Group company) is a Pharmacy Benefits Manager (PBM) for commercial plans, Medicare Part D Plans and PACE Plans.

 

Essential Functions:

 

  • Research and report relevant documentation for clients’ CMS financial audits.
  • Complete internal audits of Pharmastar’s processes and procedures, including plan set-up, price schedules and membership.
  • Prepare Pharmastar claim audit results and disseminate to clients a summary of the results.
  • Assist with compiling Quarterly Pharmastar Compliance reports.
  • Assist with preparation and analysis of PDE, P2P and FIR reports.
  • Audit and review Pharmastar’s policies and procedures.
  • Monitor Medicare Part D regulation and guidance for applicability to Pharmastar. Assist with facilitating client awareness of regulatory changes.
  • Maintain open dialogue with Pharmastar’s clients to ensure their needs are being met.
  • Generate reports to meet clients’ needs.
  • Ensures that HIPAA guidelines are followed in every communication with clients.
  • Stay current on plan and benefit structures, pharmacological updates, and Medicare Part D guidelines.
  • Attend department and company meetings and educational programs upon request.
  • Other related duties as assigned.

 

The listing of essential functions is not to be considered an exhaustive list of all duties that may be performed.

 

Qualifications:

 

  • Associate’s degree preferred. High School Diploma or equivalent required.
  • 1-2 year of customer service/call center and industry experience.
  • 1 year of Health care industry experience. (Health plan or insurance experience, a plus. PBM experience preferred.)
  • CPhT (Certified Pharmacy Technician) certification, a plus.
  • Experience in a pharmacy support role, a plus.
  • Current on plan and benefit structures and Medicare guidelines.

 

Knowledge, Skills, Abilities:

 

  • Knowledge of government health care program.
  • Knowledge of pharmacology and pharmacological terms.
  • Excellent verbal and written communication skills and professionalism when working with clients.
  • Ability to provide tactful responses under stressful situations and conditions.
  • Detail oriented with strong analytical and research skills.
  • Ability to multi-task and prioritize projects.
  • Able to maintain the highest standard of confidentiality.
  • Ability to work well with many different personality types.
  • Strong customer focus.
  • Strong computer skills including using word processors, spreadsheets, and database software.

 

Supervisory Responsibility:  None

 

Travel:  None

 

Expected Hours of Work: 

 

This is a full-time position with an expectation to work an average of 40 hours per week, and an ability to be available outside of normal business hours to meet customer expectations on an ad-hoc basis.

 

Physical Demands & Requirements: 

 

  • Communicates by way of the telephone or computer with providers, participants, customers, and vendors.
  • Operates a computer and other office productivity machinery, such as a calculator, copy machine, fax machine and office printer
  • Remains stationary for extended periods of time (i.e. sitting on a continuous basis).
  • Occasionally exerts up to 20 pounds of force to lift, carry, push, pull or move objects
  • Visual acuity to perform activities such as identifying, inputting and analyzing data on a computer terminal and/or in hard copy
  • Occasional standing, walking, climbing stairs and reaching to retrieve shelved items
  • Occasional bending/stooping

 

Work Environment: 

 

  • This job operates in a professional office environment with a conversational noise level.
  • No substantial exposure to adverse environmental conditions is expected.
  • Moderate pressure to meet scheduled appointments and deadlines

 

The Company is proud to be an equal opportunity employer. All qualified applicants will receive consideration without regard to ancestry or national origin, race or color, religion or creed, age, disability, AIDS/HIV, gender, marital or family status, pregnancy, childbirth or related medical conditions, genetic information, military service, protected caregiver obligations, sexual orientation, protected financial status or other classification protected by applicable law.

Other details

  • Pay Type Hourly
  • Telecommute % 100