Compliance Auditor - Pharmacy

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Compliance Auditor 5119 - G1

Occupational Summary

Conduct health-system wide compliance audits to ensure data integrity, compliance with federal and state regulations pertaining to but not limited to: federal healthcare program requirements, clinical trials billing, privacy, conflict of interest, and anti-kickback and physician relationships. Exercise independent decisions using analytical and problem solving skills. Provides critical analytical and support with respect to third party payer external audits (i.e. RAC, ADR/TPE, UPIC, etc.).

Work Performed

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  Interpretation of applicable federal and state law and regulations to plan audit parameters, determine department's compliance with such regulations and communicate to department necessary changes in compliance with regulatory requirements.

  
  
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  Responsible for conducting routine and non-routine audits, documenting & communicating findings and recommendations, explaining regulatory requirements, and overseeing the corrective actions for audits as assigned (20%).

  
  
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  Develop an understanding of the operations, system processes and procedures used in pharmacy and other health system areas being audited.

  
  
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  Review and test for compliance with institutional policies and procedures, applicable laws and regulations through the inspection of physical operations, processes, retrieval and review of documents and investigation of irregularities and errors (20%).

  
  
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  Compile information and/or prepare reports and analyses setting forth results of compliance audits with appropriate recommendations; perform subsequent audits to ensure complete and appropriate corrective action (20%).

  
  
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  Actively participates in exit conferences, providing clarification and supporting information necessary.

  
  
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  Performs such other functions as may be assigned from time to time.

  
  

Minimum Qualifications

Work requires a general business background generally equivalent to a Bachelor's degree in a business administration, accounting, management, healthcare administration, other related degree.Graduate Degree in finance/accounting or healthcare related field preferred.

Four years of experience related to legal, regulatory compliance, patient advocacy, supervisory role in patient financial services or HIM services, or other relevant experience.Strongly prefer 3 years of experience related to auditing and/or coding with progressive experience in auditing, pharmacy, revenue cycle compliance, and/or health information management.

None required, but auditing certification (i.e. CPA, CIA), or coding certification (i.e. CPC, CCS, CIC, RHIA, RHIT) or applicable experience is preferred (i.e. pharmacy technical

Knowledge, skills, ablilities, and Personal Characteristics

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  Knowledge of hospital and retail pharmacy revenue cycle compliance, Medicare/Medicaid regulations, including billing, coding, and documentation requirements.

  
  
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  Knowledge of the various payment systems related to hospital billing and collections and retail pharmacy billing and collections.

  
  
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  Knowledge of NC pharmacy laws and regulations, Controlled Substances Act, Prescription Drug Monitoring Programs, and HRSA 340B regulations.

  
  
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  Knowledge of the auditing process including various techniques relative to auditing and root cause analysis and resolution.

  
  
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  Strong oral and written communication skills, and strong Excel and analytical skills