What you’ll do 

In a few words…

Abarca is igniting a revolution in healthcare. We built our company on the belief that with smarter technology we are redefining pharmacy benefits, but this is just the beginning…

The Legal & Compliance department ensures our business operations and processes are compliant with all state and federal requirements. They keep Abarca updated on all regulatory and legislative developments to mitigate the impact on the services we offer! Within this team, the Pharmacy Integrity group handles FWA and related regulations to ensure we're maintaining standards and compliance in all pharmacy related processes, claims and transactions.

As our Pharmacy Integrity Specialist, you will be responsible for performing audits of pharmacies within the Company’s Provider network, as detailed in the Company’s Network Agreements. Audits are a fundamental part of maintaining a first-class and comprehensive network and must be completed with great attention to detail to prevent, identify and control potential cases of Fraud, Waste and Abuse (FWA), as defined by CMS. Additionally, as a Pharmacy Audits Specialist you must maintain excellent relations with members of the Provider Network and internal partners.

The fundamentals for the job…

• Complete in-person and long-distance audits of pharmacies within the Company’s Provider Network, paying special attention to conforming to all Company, Client, and CMS policies and procedures including prescriptions, documentation, and credentialing. 
• Collect virtual and physical evidence of claims as well as carry out pharmacy onsite audits.
• Investigate paid claims to identify errors, track patterns for possible cases of FWA. 
• Prepare quarterly reports on audit processes and timelines, detailing recent findings, determining overpayments as well as submit findings adequately.
• Analyze FWA referrals from clients, other departments, members, and hotline calls.
• Review and promptly respond to requests for information from law enforcement agencies and plan sponsors (clients). 
• Analyze audit findings to determine validity of any identified discrepancies while bearing the full responsibility of identified issues during audits. 
• Write the final audit discrepancies notification letter and audit report for pharmacies. 

What we expect of you

The bold requirements… 

• Pharmacy Technician Associate Degree (In lieu of a degree, equivalent relevant work experience may be considered.)
• 3 years of experience in a related role.
• Experience working with fraud, waste and abuse regulations and industry trends.
• Experience in handling full analysis, from issue identification up to providing reports.
• Excellent oral and written communication skills. Bilingual fluency in English and Spanish is required.
• We are proud to offer a flexible hybrid work model which will require certain on-site workdays (Puerto Rico Location Only)

Nice to haves… 

• Specialty Pharmacy experience is preferred.
• Experience within the Healthcare, Pharmacy Benefit Management, and Insurance industries is a plus. 
• Certified Fraud Examiner. 
• Experience related to CMS and Medicare Part D is preferred. 

Physical requirements…

• Must be able to access and navigate each department at the organization’s facilities.
• Sedentary work that primarily involves sitting/standing.

The above description is not intended to limit the scope of the job or to exclude other duties not mentioned. It is not a final set of specifications for the position. It’s simply meant to give readers an idea of what the role entails.

Abarca Health LLC is an equal employment opportunity employer and participates in E-Verify. “Applicant must be a United States’ citizen. Abarca Health LLC does not sponsor employment visas at this time”

All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of gender, race/ethnicity, gender identity, sexual orientation, protected veteran status, disability, or other protected group status.

#LI-NO1 #LI-REMOTE