Role Description

Seeking a Clinical Review Pharmacy Analyst responsible for utilizing knowledge of drugs and pharmaceuticals to conduct post-service audits and ensure the accuracy of billed charges. This role analyzes billing and medical documentation to determine whether charges align with medical records, pharmaceutical treatments, and reimbursement policies. The position requires strong analytical ability, familiarity with healthcare documentation, and the ability to maintain productivity and quality standards within a fast-paced environment.

This is a temporary contract position working remotely within the United States. Candidates must be able to work Pacific Time Zone hours.

Key Responsibilities

• Conduct post-service audits using knowledge of drugs and pharmaceuticals to ensure billing accuracy.
• Prioritize work, set goals, and coordinate activities to ensure timely completion of record reviews and audits according to team workflow.
• Analyze billings to determine if charges are consistent with medical records, drug administration, and reimbursement policies.
• Identify incorrectly billed medications, IV fluids, and pharmaceutical treatments.
• Evaluate documentation to determine investigational or off-label drug use when applicable.
• Identify when additional information is required and request supporting documentation when necessary.
• Follow strict guidelines to ensure work meets corporate standards for accuracy, timeliness, quality, and regulatory compliance.
• Maintain organized access to reference materials, policies, and procedures required to perform audits.
• Complete assigned work while meeting productivity and quality standards.
• Support departmental efficiency through flexibility and cross-training on additional functions.
• Perform special projects as requested by the supervisor.

Qualifications

• Demonstrated competency in claim review and experience using billing and claims forms.
• In-depth knowledge of drugs and pharmaceuticals to identify incorrectly billed medications and IV fluids.
• Ability to identify drug use for non-FDA approved treatments, investigational use, or off-label administration.
• Familiarity with healthcare documentation.
• Strong oral and written communication skills.
• Demonstrated initiative and strong problem-solving skills.
• Ability to consistently meet productivity and quality standards with minimal supervision.
• Ability to work in a fast-paced, multi-tasking environment with changing priorities.
• General computer skills including Microsoft Office, Outlook, and Internet research.
• Experience with AI tools and technologies to enhance productivity and decision-making in professional settings is highly desired.

Requirements

• A license or certification as a Pharmacy Technician or Licensed Practical Nurse.
• 2 years of experience in a hospital or residential treatment facility.
• 3 years of health insurance claims experience or analytical experience, or an equivalent combination of education and experience.
• Payment review or coding experience is considered a plus.

Required Licenses or Certifications

• Licensed Practical Nurse (LPN)
• Licensed Pharmacy Technician

Work Environment

• Work is primarily performed in an office environment while working remotely.
• Candidates must be willing to work Pacific Time Zone hours and may occasionally be required to work outside normal business hours.
• Local or out-of-state travel may be required.
• Company-provided equipment will be used.