Quality and Regulatory Sr Auditor

Essential Functions

  • Demonstrate in-depth understanding of OutcomesMTM business, MTM claim submission requirements, and MTM claim validation specifications
  • Develop and manage an inventory of quality assurance system edits and coordinate with other departments to adjust, as needed 
  • Provide advanced support of various components of the OutcomesMTM business, including MTM service requirements, MTM claim documentation requirements, and quality assurance system edits
  • Review data quality reports, identify inconsistencies and opportunities for improvement
  • Identify and resolve MTM activity issues 
  • Evaluate reports to identify pharmacies showing atypical MTM activity
  • Coordinate with internal departments to educate and correct outliers
  • Provide content for network communications advising on appropriate claim documentation for common billing errors
  • Measure network performance in OutcomesMTM programs
  • Audit OutcomesMTM network providers, as needed
  • Develop and maintain network educational materials related to policies, procedures and documentation requirements, including the Policy and Procedure guide
  • Facilitate modification and review of program policies and procedures
  • Create and maintain internal quality assurance user guides
     

Skills

  • Healthcare experience strongly preferred
  • Ability to meet multiple deadlines
  • Strong written and verbal communication skills
  • Ability to communicate across all levels of an organization, demonstrating professionalism and good judgment at all times
  • Must be able to work autonomously (with minimal direction) while also being part of an integrated team
  • Must be able to manage competing demands and multiple priorities, while maintaining a strong attention to detail
  • Strong quantitative, qualitative, and analytical skills including technical proficiency related to PC and basic office software