Pharmacy Claims Auditor - Remote

Prime Therapeutics•Home, WV

2d•$25 - $41•Remote

About The Position

The Pharmacy Claims Auditor is responsible for identifying and evaluating potential waste and compliance through the pharmacy audit process and educating Prime’s network pharmacies and driving contract compliance. This position will research, analyze and compile supporting information. This role will also execute and support audit-related projects, best practices in identifying audit trends, and business value opportunities for Prime and our clients.

Requirements

Bachelor’s degree in Health Science or related area of study, or equivalent combination of education and related work experience; High school diploma or GED required
2 years of work experience in retail, long term care, specialty, home infusion, or mail order pharmacy or combined pharmacy and Pharmacy Benefit Management experience to include 1 year of work experience in an operations, audit or quality assurance environment
National Pharmacy Technician Certification through PTCB, ExCPT (CPhT)
Must be eligible to work in the United States without the need for work visa or residency sponsorship
Change agile; willing and able to adjust individual and team direction based upon changing priorities and business need while working with a high degree of autonomy
Ability to think critically, problem solve and use appropriate judgement to make decisions and provide risk advice to internal and external partners while anticipating the broad impact of decisions
Ability to establish trust, respect and credibility and form effective working relationships with individuals at all levels of an organization; collaborate effectively cross-functionally and with clients and other key stakeholders
Ability to distill complex concepts or situations into concise and compelling communications
Ability to interact positively and professionally during all pharmacy interactions and effectively de-escalate potentially confrontational situations
Proficiency in MS Word, Excel, and database software
Intermediate skill and understanding of the point of sale and on-line pharmacy claims processing environment

Nice To Haves

3 years of previous audit experience
Current Registration with State Board of Pharmacy in the state where position is located
Previous PBM experience
Previous retail or specialty pharmacy technician experience

Responsibilities

Conduct in-depth analysis of large datasets and audit findings to detect high-risk pharmacy claims, identify billing irregularities, and uncover patters of non-compliance or systemic errors
Research and select appropriate audit samples strategically, prioritize pharmacy claims and providers for review based on risk indicators and compliance concerns
Evaluate pharmacy claims and supporting documentation to determine whether claims align with contractual terms, provider manual policies, and applicable state/federal regulations
Educate pharmacies on documentation standards and compliance best practices, while supporting accurate data and financial reimbursement to ensure appropriate claim corrections or reversals
Other duties as assigned