MedImpact Healthcare Systems, Inc.

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Claims Quality Audit Analyst I

at MedImpact Healthcare Systems, Inc.

Posted: 3/9/2020
Job Reference #: 5930
Keywords: compliance

Job Description

San Diego, CA
Remote Location:

# of openings:

Employment duration:
Full time
Exemption Status:

Relocation Assistance:
Added to system:
12/13/18 11:06 AM

Job Code:

Claims Quality Audit Analyst I

If you’re interested in a career within a customer-focused, team-oriented environment that rewards innovation, quality, integrity and collaboration, MedImpact Healthcare Systems, Inc. welcomes your application. MedImpact, is a privately-held pharmacy benefit manager (PBM) headquartered in San Diego, California. Our solutions and services positively influence healthcare outcomes and expenditures, improving the position of our clients in the market. MedImpact offers high-value solutions to payers, providers and consumers of healthcare in the U.S. and foreign markets.

Position Summary: 

The Claims Quality Audit Analyst I (CQAA) serves as the claims adjudication subject matter expert for audits and the main point of contact related to audit-related claims research.  This individual has a broad understanding of the different systems, processes, and configurations that impact claims adjudication, and can work with other areas of the business to provide comprehensive responses to claims adjudication questions.  This employee performs oversight of their clients’ claims adjudication accuracy, and meets with clients to understand their QA and compliance programs to align their claims oversight processes with these programs.  Relying on experience and knowledge, the CQAA is responsible for accomplishing assignments that reflect substantial variety and complexity. They review reports with large amounts of data to ensure high accuracy for clients.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

  • Executes Microsoft Access® database queries used to validate the accuracy of claims audit universes and to automate responses to claims adjudication questions and performs quality control on the output, checking both response accuracy and field format.
  • Works closely with internal teams, CMS, Plan Sponsors, and a wide variety of audit firms to provide detailed responses to claims universes questions, audit inquiries and other issues arising for POS adjudication. 
  • Participates in CMS Program and client oversight claims audit reviews; demonstrates production claims processing and provides screen shots as necessary.
  • Provides basic claims oversight through pro-active, independent quality review of claims per defined frequency conducted by random sampling, targeted review based on upstream changes (system, program, process and client), and through algorithms. 
  • Performs Benefit Change Request (BCR) quality review using experience and knowledge of benefits, claim adjudication rules and POS edits.
  • Run monthly, quarterly and annual reports for Performance Guarantees (PG). Tracking and monitoring all enhancements and new implementations. Provides input when necessary to the PG Team.
  • Preparing claims impact analyses through writing medium complexity SQL queries, and using experience and knowledge of claims processing systems to determine parameters to provide requested information.
  • Audits established guidelines for CMS required measurements.
  • Ensures the accuracy of reimbursement payments, member Out of Pocket (OOP), accumulators and verifies that benefits were paid correctly and in accordance with appropriate plans and policies.
  • Communicates any errors/issues discovered and provides suggestions for impact analysis as appropriate.
  • Assists with the development of process improvements for the department that includes reviewing daily processes and providing suggestions to leadership.

Education and/or Experience

For consideration candidates will need a Bachelor's degree (B.A.) from four-year College or university and three (3) to four (4) years of benefits coding or configuration experience required in Pharmacy Benefit Management (PBM), Pharmacy systems management and claims processing, claims auditing, testing and validation or related Managed Healthcare experience; or an equivalent combination of education and experience.

Computer Skills

  • Intermediate to advanced knowledge of MS Office / Word, PowerPoint, and Outlook
  • Advanced knowledge of MS Excel
  • Working knowledge of key business applications such as SQL queries, Oracle forms, Golden 32, MedAccess, MedAccess Classic, MS Access, MedOptimize, Visio, or others as applicable to the role
  • Ability to run SQL queries and scripts

Certificates, Licenses, Registrations

Current Pharmacy Technician License and/or CPhT certification without restriction preferred

Other Skills and Abilities

  • Ability to effectively balance a high volume of work and a variety of tasks and prioritize urgent issues effectively
  • Strong analytic, verbal and written communication skills
  • Detail-oriented with high degree of accuracy and organizational skills
  • Able to effectively work as a team player
  • Excellent investigative, problem resolution, judgment and decision- making skills required
  • Excellent presentation and consultative skills, working with internal and external clients at various levels in the organization
  • Possesses a cross-functional understanding of Part D processes within different departments
  • Understands the Medicare Part D and other lines of business configurations at the client level for areas such as Benefits and Pharmacy Networks, Claims Adjudication and Formulary

This position is eligible for Employee Referral Bonus at Level I



To perform this job successfully, the successful candidate must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.


The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.