Remote
Audit & Appeals Specialist is responsible for the administration and coordination of pharmacy benefit manager (PBM), payer, and payment integrity audits for Biologics by Client. This role serves as the primary operational resource for receiving, processing, tracking, researching, responding to, and closing audit requests while ensuring compliance with contractual, regulatory, and payer requirements.
The Specialist manages a high-volume audit environment consisting of prescription validation reviews, desk audits, field audits, real-time audits, and other payer review activities. The position also supports preparation of audit appeals, objections to audit scope, documentation collection, and audit outcome tracking designed to minimize recoupment risk and protect organizational revenue. Audit activity exceeds 1,700 requests annually and requires strong organization, regulatory knowledge, and attention to detail.
Primary Responsibilities Audit Intake and Administration
- Receive and review PBM, payer, and payment integrity audit requests.
- Log and track audit requests through completion.
- Establish and monitor audit deadlines and escalation requirements.
- Coordinate audit activity with pharmacy operations, compliance, revenue cycle, and leadership teams.
- Maintain complete audit documentation and records.
Audit Response Development
- Gather and validate documentation required for audit responses.
- Review pharmacy records, claims, prescriptions, shipping documentation, and supporting materials for completeness and accuracy.
- Prepare audit response packages in accordance with payer requirements.
- Ensure timely submission of audit responses and supporting documentation.
Appeals and Audit Defense
- Research audit findings and potential recoupments.
- Assist in the development and submission of audit appeals.
- Support preparation of objection letters related to audit scope and audit methodology.
- Identify applicable payer contract provisions, provider manual requirements, and state pharmacy audit regulations.
- Escalate significant financial, operational, or regulatory concerns to leadership.
Risk Management and Reporting
- Monitor audit trends, audit outcomes, and recoupment activity.
- Track appeal success rates and recovery opportunities.
- Identify recurring operational and documentation issues that increase audit risk.
- Develop reports and dashboards for management review.
- Recommend process improvements to reduce future audit exposure.
Compliance and Regulatory Support
- Maintain working knowledge of PBM audit requirements and pharmacy audit regulations.
- Support internal audit-readiness initiatives.
- Assist with policy, procedure, and documentation reviews related to audit findings.
- Partner with accreditation and compliance personnel on corrective actions when appropriate.
Qualifications Required
- 3+ years of experience in specialty pharmacy, PBM audits, pharmacy compliance, payer operations, revenue integrity, or related healthcare operations.
- Experience reviewing pharmacy claims, prescription documentation, and payer requirements.
- Strong written communication and documentation skills.
- Advanced Microsoft Excel, Word, and Outlook proficiency.
- Ability to manage multiple concurrent deadlines with minimal supervision.
- Strong analytical, organizational, and problem-solving skills.
Preferred
- Specialty pharmacy experience.
- Experience with PBM audits, payment integrity reviews, or prescription validation audits.
- Familiarity with state pharmacy audit laws and PBM provider manuals.
- Experience developing audit appeals and recoupment disputes.
- Knowledge of specialty pharmacy accreditation standards (URAC and/or ACHC).
Key Competencies
- Attention to detail
- Regulatory and compliance awareness
- Critical thinking
- Professional written communication
- Project and workload management
- Financial risk awareness
- Cross-functional collaboration
- Independent judgment
Success Measures
- Timely completion of audit responses.
- Audit tracking accuracy and documentation completeness.
- Appeal submission timeliness.
- Reduction in avoidable recoupments.
- Compliance with payer and regulatory deadlines.
- Effective management of a high-volume audit workload.
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