• The Pharmacy Network Auditor is responsible for the maintenance and growth of the Pharmacy Network Audit program and processes at RxSense • Evaluates, reports and monitors all aspects pertaining to Pharmacy Network Auditing services • Serves as a subject matter expert regarding standard monitoring measures, auditing procedures, and best practices • Assesses risks suggested by audit vendor, performs appropriate audit procedures, and collaborates with pharmacy management for efficient issue resolution • Drafts and communicates audit findings to internal stakeholders; provides Quarterly Network Audit Performance Reports to leadership • Screens and summarizes authorized vendor audit results • Reviews results to identify fraudulent, erroneous, or abusive billing activity • Analyzes claims data for potential investigational FWA breaches of network pharmacies • Maintains audit documentation, and prepares statistical data for review and action • Develops and updates Standard Operating Procedures for audit and FWA Programs • Collaborates with key stakeholders to support pharmacy network initiatives.

Title: Professional Coding Auditor & Educator Location: Silver Spring United States Job Description: Location Silver Spring, Maryland, 20910 Category Finance & Revenue Management Job Id 00677755 Holy Cross Health - Employment Type: Full time Shift: Day Shift Description: Employment Type: Full-Time Shift: Days (SUMMARY) Position Highlights: - Competitive pay - Additional Benefits: tuition reimbursement, free parking, employee discounts - Quality of Life: Flexible work schedules - Advancement:  professional growth within the organization - Location: Holy Cross Health has two hospitals and four healthcare centers all a short driving distance from Washington DC and Baltimore, MD.  Description: - Monday-Friday The Professional Coding Auditor Educator performs medical record audits including but not limited to analysis of medical record documentation, validation of primary and secondary diagnoses and procedures; and ensuring proper assignment of diagnosis and procedure codes using coding guidelines established by the Centers for Medicare and Medicaid Services (CMS).  Responsibilities: - Monitors accuracy of centralized coders’ charge capture and coding with proper ICD-10, CPTs, as well as proper modifiers, adhering to local ministry and Trinity practices and policies. - Partners with leadership to improve HCC, high risk scoring, with provider and coder education. - Conducts ongoing reviews of patient medical record documentation and procedural and diagnosis coding by each practitioner. - Responsible for practitioner education in areas related to coding, documentation, and compliance. - Works closely with leadership and the department to establish and modify the charge description master (CDM) methodology and pricing models to ensure accuracy and regulatory compliance. - Reports to the Manager, Provider Revenue Operations What you will need: - High school diploma or equivalent combination of education and experience - Certified Professional Coder or Registered Health Information Technician accreditation required. - Minimum of 2-5 years of professional coding experience with comprehensive knowledge of ICD-10, CPT, and HCPCs modifiers.  Knowledge of Medicare, Medicaid, and other third-party billing rules and regulations. - 3-6 years of professional coding experience; ability to code from operative reports; prior auditing experience.( Preferred) - Effective verbal, written, and interpersonal communication skills with the ability to comfortably interact with diverse populations. - Ability to work collaboratively in a team-oriented environment with a strong customer-service orientation. - Ability to handle patient and organizational information in a confidential manner. - Ability to demonstrate competency with a standard desktop and Windows-based computer system, including a basic understanding of email, e-learning, intranet and computer navigation.  Ability to use other software as required to perform the essential functions of the job. - Demonstrated dependability and regular attendance. - Solid understanding of ICD-10 and CPT coding and medical terminology, with knowledge of Medicare, Medicaid, Health Maintenance Organization and commercial insurance plans. - Ability to exercise independent judgment as appropriate within standard practices and procedures. Pay rate: $ 28.00 – $43.40 Pay is based on experience, skills, and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location. About us: Holy Cross Health is a Catholic, not-for-profit health system that serves more than 240,000 individuals each year from Maryland's two largest counties — Montgomery and Prince George's counties. Holy Cross Health earns numerous national awards, clinical designations and accreditations across a wide range of specialties for providing innovative, high-quality health care services. We were named one of America’s 100 Best Hospitals for 2021. Holy Cross Health is an Equal Employment Opportunity (EEO) employer.  Qualified applicants are considered for employment without regard to Minority/Females/disabled/Veteran (M/F/D/V) status Our Commitment Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

• Perform certification audits in any capacity in conformance with the SGS Global/Local procedures, sector specific schemes/standards. • Ensure that such duties are performed in an efficient and commercially expedient way. • Collaborate with teams of Auditors during the auditing activities. • Assist in the training of other Auditors and Senior Auditors during planned audits or during other training functions. • Actively participates in witness audits by SGS or accreditation bodies. • Undertake any other activities as directed by the Manager, Certification Audit or Manager, Technical Accreditation.

• Conducts internal and external timely operational, compliance, and financial audits of divisions, departments, providers, and activities of the corporation including evaluation of internal controls • Identifies, documents, and evaluates business risks • Documents issues, the causes of those issues, and their effects on the process/function and the corporation • Drafts recommendations to limit risks and improve processes, functions and activities • Writes audit reports for corporate executive management that clearly and effectively convey engagement evaluations, conclusions, and recommendations • Collects and analyzes data to detect deficient controls, duplicated effort, fraud, or non-compliance with laws, regulations, and management policies • Conducts testing of corrective actions as identified • Develops detailed reports on each audit conducted • Examines and evaluates financial and information systems, recommending controls to ensure system reliability and data integrity • Conducts special audit studies for management, such as those required to discover controls for prevention of fraud • Prepares reports of findings and recommendations for management • Assists other auditors in completing their assignments as a means of maximizing audit efficiency