Sr ConsultantSpecialty Audit

Job Description
Responsible for managing and providing support for all Payer related audits of the Specialty Services Division

Provide support for all Payer audits
Review and analyze audit findings on all audits performed and prepare communication package for such audit
Review payer audit results in detail and confirm accuracy all aspects of payer documentation related to specific services, to include review of payments received, quantities provided, billed charges, prescribed quantities, contractual obligations/pricing, payer requirements and applicable laws/regulations.
Resolve open issues, status, and financial assessments
Aid in coordinating the scheduling and administration of all on-site audit visits.
Coordinate with Division locations for response to on-site payer audits and ensure availability of documentation necessary to supplement clinical records and staff member availability to respond to inquiries beyond the clinical scope.
Responsible for managing and reviewing payer state and federal government payer and private payer audit requests/inquiries to ensure timely notification and response for the Division, including coordinating documentation, initial research and audit interface, and coordinating Division audit response
Communicate audit process to internal staff members, maintain payer audit files and payer audit database/reporting
Image audit documentation via image database.
Participate in on-going training to educate internal and branch/field staff on the proper Payer Audit S.O.P. and ensure that those guidelines are adhered to.
Identify processes within Caremark that may be deficient and recommend improvement.
Interface with outside auditors, clients, and all departments within Caremark to resolve audit issues.
Organize, analyze, review, repayment errors such as co-pay, discount, set-up, pricing, coverage, etc.

Required Qualifications
Prior auditing or legal review experience desired
PC proficiency in Microsoft Word & Excel
5 - 7 years experience within a legal, public accounting or managed care environment
Strong project management skills
Strong analytical ability

COVID Requirements
COVID-19 Vaccination Requirement
CVS Health requires its Colleagues in certain positions to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, pregnancy, or religious belief that prevents them from being vaccinated.
  • If you are vaccinated, you are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status within the first 10 days of your employment. For the two COVID-19 shot regimen, you will be required to provide proof of your second COVID-19 shot within the first 45 days of your employment. Failure to provide timely proof of your COVID-19 vaccination status will result in the termination of your employment with CVS Health.
  • If you are unable to be fully vaccinated due to disability, medical condition, pregnancy, or religious belief, you will be required to apply for a reasonable accommodation within the first 10 days of your employment in order to remain employed with CVS Health. As a part of this process, you will be required to provide information or documentation about the reason you cannot be vaccinated. If your request for an accommodation is not approved, then your employment may be terminated.

Preferred Qualifications
Ability to speak clearly and concisely in small and large group settings
Ability to write clear audit finding reports
Ability to interact with all levels of management
Ability to analyze and quantify audit issues
Ability to make process improvement recommendations based upon audit findings
Ability to conduct detailed audit analysis utilizing clinical information, review and analysis of applicable contractual terms, applicable payer guidelines, regulations/law and formulate detailed audit response
Ability to handle complicated or sensitive matters with internal or external auditors, including Program Integrity Units, Fraud and Abuse Auditors, Medicaid Program Directors
Ability to investigate and resolve audit issues through the use of computerized program tools etc.

Undergraduate degree in business or related background

Business Overview
At CVS Health, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, sex/gender, sexual orientation, gender identity or expression, age, disability or protected veteran status or on any other basis or characteristic prohibited by applicable federal, state, or local law. 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.