Pharmacy Contract Audit Analyst

Job not on LinkedIn

🔥 3 minutes ago

🇺🇸 United States – Remote

💵 $54.2k - $64.6k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

🧐 Analyst

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Navitus Health Solutions

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2003

💼 Consulting

🛡️ Insurance

🏥 Healthcare

Consulting • Insurance • Healthcare

Navitus Health Solutions is a pharmacy benefit manager (PBM) that provides transparent, people-centered pharmacy benefit solutions to health plans, employers, government programs and other plan sponsors. The company operates a 100% pass-through, cost-plus model that emphasizes lowering medication costs, managing formularies, specialty drug management (including a cost-plus specialty pharmacy), claims adjudication, pharmacy network management, and member enablement and support services. Navitus positions itself as a fiduciary partner focused on affordability, compliance, clinical quality and improving health outcomes through tailored PBM services and digital health integrations.

📋 Description

• Oversee Navitus’ contractual pharmacy network reimbursement accuracy • Independently assess compliance with contractual reimbursement obligations in Retail, Specialty, and Mail Order pharmacy agreements • Review and monitor claims data • Create and update procedures • Audit networks for price change accuracy • Monitor compliance with pharmacy provider contracts • Communicate findings and work with applicable teams to remediate errors • Interpret contractual terms, client network selections, and their operationalization in applicable systems • Utilize Navitus’ adjudication system (NCRx) and contracting and credentialing databases (PC2), among other applications • Analyze provider, client, and network performance for network development, quality control, and contractual compliance • Create reports validating systems accuracy against Retail, Specialty, and Mail Order contractual terms • Field, analyze, and resolve pricing-error inquiries from pharmacy providers, clients, auditors, and internal teams, focusing on root cause • Develop and maintain controls and oversight reporting for contract pricing • Identify, define, and implement new processes when controls are absent • Conduct pharmacy network rate testing, chain audits, and impact assessments • Submit service requests and recovery requests and engage applicable teams for system updates or changes • Report contractual compliance activities and opportunities to the Provider Services team and cross-functional leadership • Perform other duties as assigned

🎯 Requirements

• Bachelor’s degree or equivalent experience required • Emphasis in business, finance, economics, or operations preferred • Minimum two years analytics experience required • Analytical and operational understanding of Navitus’ reimbursement programs including AWP, WAC, MAC, NADAC, FUL, AAC, Average Dispensing Fee, and other pricing structures • Ability to interpret pharmacy contract language and compare contract pricing to adjudicated claims activity • Ability to develop and maintain controls and oversight reporting • Ability to perform pharmacy network rate testing, chain audits, analysis, and impact assessment • Ability to make decisions regarding pharmacy network pricing setup issues • Ability to understand, follow, and improve operational and administrative processes • Ability to participate in, adhere to, and support compliance program objectives • Ability to consistently interact cooperatively and respectfully with other employees • Ability to work remotely from an eligible US state; remote work unavailable to residents of Alaska, Hawaii, Maine, Mississippi, New Hampshire, New Mexico, North Dakota, Rhode Island, South Carolina, South Dakota, West Virginia, and Wyoming

🏖️ Benefits

• Top of the industry benefits for Health, Dental, and Vision insurance • 20 days paid time off • 4 weeks paid parental leave • 9 paid holidays • 401K company match of up to 5% - No vesting requirement • Adoption Assistance Program • Flexible Spending Account • Educational Assistance Plan and Professional Membership assistance • Referral Bonus Program – up to $750! • M-F 8:00am-5:00pm schedule