Job Description :
This job maintains the Designated Pharmacy Program (DPP) which includes reviewing medical and prescription drug claims to identify members who exhibit unsafe prescription drug behavior and help members obtain care alignment and/or addiction treatment. The incumbent reviews high prescriber investigations, works with MD's to assess medical necessity of medications and identify potential red flags of fraud across provider prescribing patterns, etc.
- Maintain the Designated Pharmacy Program (DPP) which includes reviewing medical and prescription drug claims to identify members who exhibit unsafe prescription drug behavior and help members obtain care alignment and/or addiction treatment.
- Conduct review of areas or programs as requested both internally and externally using department case protocol: (a) Identify high prescribers by reviewing inquiries/complaints, data mining reports, etc., (b) Interview providers, members or any other individual(s) necessary to complete a case review or special project, (c) Determine the scope of the allegation or special project by assembling the necessary information, statistics, policies and procedures, licensure information, doctor’s agreements, contract, etc., (d) Coordinate data extracts by assessing multiple databases both internally and externally, and (e) Take action to prevent further improper payments.
- Review and analyze claims data, applying knowledge of pharmacy policy/practice and data mining techniques to determine details of over-payment billing activity while assisting with oversight of program.
- Monitor and report accordingly any compliance issues with regulatory requirements.
- Identify and document fraudulent or erroneous activities.
- Participate in Pharmacy related Fraud, Waste and Abuse measurement projects, helping to develop enhanced data analysis systems and serving as a resource for developing Fraud, Waste and Abuse investigative results and solutions.
- Handle allegations of potential pharmacy fraud.
- Review and analyze claims data, applying knowledge of pharmacy policy/practice and data mining techniques to determine details of overpayment billing activity while assisting with oversight of contracted program.
- Other duties as assigned or requested.
- 3 years Pharmacy Technician or Pharmacy Audit
LICENSES or CERTIFICATIONS
- Oral and Written Communication Skills
- General Computer Skills
- Problem Solving and Decision Making
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