CVS Health

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Pharmacy Claims Auditor

at CVS Health

Posted: 3/27/2020
Job Reference #: 1227517BR
Keywords: compliance

Job Description

Job Description
This position is an exciting opportunity to join a specialized team of auditors as part of CVS Caremark's extensive Pharmacy Audit division. The Medicare Pharmacy Claims Auditor will administer assigned Medicare Part D Compliance Audit Programs, review pharmacy submitted Medicare claims, make independent decisions, and call network pharmacies to audit submitted information and communicate business requirements. Candidates will work as part of a specialized team of auditors, working together to successfully complete audit projects. Candidates must be highly motivated, possess strong communication skills, effective time management skills, and be very detail-oriented. Candidates will become an expert on the CVS Health Medicare Audit Programs and will own one or more of those audit program processes on an ongoing basis. Candidates must possess extremely strong teamwork and collaboration skills and be skilled in sharing common workloads with peers. Candidates will have expansive opportunities to innovate and develop new tools to enhance the execution of audit programs, and work with internal and external partners to develop successful solutions within the scope of the processes for which they are accountable.

Daily tasks may include:

- Telephone outreaches to network pharmacies to verify claim information
- Transmission of audit requests to pharmacies
- Review of hard copy prescriptions to verify compliance with CMS requirements and CVS Health contractual requirements
- Review of incoming documentation from pharmacies and input information into internal CVS Health audit systems
- Corresponding with network pharmacies to answer questions regarding Medicare Audit Programs Monitor assigned audit processes and report status on a regular basis
- Meeting with internal partners to develop and communicate business objectives
- This role will work closely with internal and external partners to conduct audits which help keep CVS Health plans in compliance with CMS requirements and maintain positive STAR ratings

Required Qualifications
-1+ year(s) combined experience in a PBM or pharmacy

Preferred Qualifications
- 5+ years combined experience in a PBM or pharmacy
- 2+ year(s) experience in pharmacy or PBM claim processing systems
- Bilingual candidates preferred
- Spanish language fluency preferred
- Familiarity with current CMS Medicare Part D compliance regulations
- Advanced level of technical skillsets including Microsoft Excel, Microsoft Access, SQL databases
- Team player and collaborative attitude
- PTCB licensure

Verifiable High School Diploma or GED required. Bachelor's Degree strongly preferred.

Business Overview
It’s a new day in health care.

Combining CVS Health and Aetna was a transformative moment for our company and our industry, establishing CVS Health as the nation’s premier health innovation company. Through our health services, insurance plans and community pharmacists, we’re pioneering a bold new approach to total health. As a CVS Health colleague, you’ll be at the center of it all.

We offer a diverse work experience that empowers colleagues for career success. In addition to skill and experience, we also seek to attract and retain colleagues whose beliefs and behaviors are in alignment with our core values of collaboration, innovation, caring, integrity and accountability.

CVS Health is an equal opportunity/affirmative action employer. Gender/Ethnicity/Disability/Protected Veteran - we highly value and are committed to all forms of diversity in the workplace. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities. We comply with the laws and regulations set forth in the following EEO is the Law Poster: EEO IS THE LAW and EEO IS THE LAW SUPPLEMENT. We provide reasonable accommodations to qualified individuals with disabilities. If you require assistance to apply for this job, please contact our Advice and Counsel Reasonable Accommodations team. Please note that we only accept applications for employment via this site.

If technical issues are preventing you from applying to a position, contact Kenexa Helpdesk at 1-855-338-5609 or For technical issues with the Virtual Job Tryout assessment, contact the Shaker Help Desk at 1-877-987-5352.

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!