The Senior Pharmacy Audit & Revenue Integrity Specialist is responsible for ensuring compliance with pharmacy billing practices, auditing processes, and revenue cycle operations. This role involves conducting detailed reviews of pharmacy invoices, validating drug pricing and fees, and ensuring adherence to contract terms and regulatory requirements. The specialist plays a key role in identifying discrepancies, performing root cause analyses, and preparing comprehensive audit reports for healthcare entities, including public-sector organizations.

Key Responsibilities:

Conduct manual exception reviews and audits of pharmacy billing for hospitals and healthcare facilities.

Review and validate pharmacy invoices, including ingredient costs, dispensing fees, and administrative/service fees, against contracted pricing methodologies such as AWP, WAC, and U&C pricing.

Investigate and resolve pricing discrepancies, including unit-of-measure errors, incorrect NDC mappings, and misapplication of pricing tables.

Ensure compliance with Medicare and Medicaid pharmacy billing requirements and institutional billing practices.

Prepare detailed audit documentation, financial impact analyses, and regulatory reports for management and external stakeholders.

Collaborate with finance and compliance teams to address billing discrepancies and support audits.

Areas of Expertise:

Pharmacy billing audits and charge integrity processes. Contract compliance, including rates, fees, and pricing formulas.

Transaction-level repricing and validation of drug pricing methodologies. Institutional and inpatient pharmacy billing practices.

Regulatory reporting and audit documentation for healthcare entities.

Qualifications:

Licensed Pharmacist with extensive experience in pharmacy revenue cycle operations and auditing.

Strong knowledge of drug pricing methodologies, including AWP, WAC, and U&C pricing. Proven ability to manage high-volume pharmacy billing audits and ensure contract compliance.

Experience in preparing audit reports for public-sector and government healthcare entities.

This role requires a detail-oriented professional with a strong background in pharmacy operations, auditing, and compliance, capable of ensuring accurate billing practices and supporting healthcare organizations in maintaining financial integrity. Full company benefits will be available upon hire.

ProRec Resource Solutions, LLC

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Senior Pharmacy Audit & Revenue Integrity Specialist