Pharmacy Claims Reviewer

VytlOne•Remote,

9d•$27 - $30•Remote

About The Position

The 340B Pharmacy Claims Reviewer performs scheduled reviews of prescription claims and supporting documentation to verify 340B eligibility, identify potential diversion or duplicate discounts, and support accurate claim qualification. The role documents and reconciles findings, monitors trends, and collaborates with the assigned 340B Account Specialist and other internal stakeholders to strengthen compliance, data integrity, and realized program savings.

Requirements

Two years of experience in pharmacy operations, pharmacy claims, healthcare auditing, 340B program support, or a related healthcare environment required.
Working knowledge of 340B Drug Pricing Program requirements, pharmacy claims processing, patient eligibility, duplicate discount prevention, diversion prevention, and audit documentation.
Ability to review and interpret prescription claims, medical records, insurance information, provider referrals, and related documentation accurately and consistently.
Strong analytical, reconciliation, problem-solving, and attention-to-detail skills.
Ability to document findings, maintain accurate audit records, identify trends, and communicate deficiencies and improvement opportunities clearly.
Proficiency with Microsoft Office applications and the ability to learn and use 340B, pharmacy, claims, and client-specific systems.
Ability to manage multiple priorities, meet established deadlines, protect confidential information, and work independently in a remote environment while collaborating effectively with internal stakeholders.

Nice To Haves

Associate degree in pharmacy technology, healthcare administration, business, or a related field preferred. An equivalent combination of education and relevant experience may be considered.
Active pharmacy technician certification (CPhT) preferred.
Experience reviewing prescription claims, patient eligibility, medical records, or Medicaid billing is preferred.

Responsibilities

Perform scheduled audits of prescription claims and supporting documentation in accordance with established procedures, client requirements, and service-level expectations.
Research and resolve reconciliation exceptions identified during monitoring and claims review; escalate unresolved or material issues as appropriate.
Review Medicaid claims and related indicators to identify and help prevent potential duplicate discounts.
Evaluate 340B patient eligibility and claim qualification, including in mixed-use settings and clinics, by reviewing patient medical records, prescription details, insurance information, provider relationships or referrals, and hospital or encounter status, as applicable to the company’s responsibilities to the client.
Verify that required documentation supports 340B eligibility and identify missing, incomplete, or inconsistent information that affects claim qualification.
Accurately record audit results, reconciliation activity, supporting rationale, and follow-up actions in designated systems or tracking tools.
Identify recurring trends, process gaps, and potential compliance risks, and communicate findings and improvement opportunities to the assigned 340B Account Specialist and other appropriate stakeholders.
Collaborate with internal teams to clarify documentation, resolve claim qualification issues, and support consistent application of established 340B criteria.
Protect patient, prescription, and client information and follow all applicable privacy, security, and confidentiality requirements.
Promote and comply with the VytlOne Business Code of Conduct, Ethical Business Conduct policy, Compliance Program, and other company policies and procedures.
Promptly report suspected misconduct, compliance concerns, or allegations of impropriety through the appropriate reporting channels, including the Compliance Department.
Remain eligible to participate in federal healthcare programs and free from exclusion on the Office of Inspector General and System for Award Management exclusion lists.
Complete required training within established timeframes and maintain job-related knowledge through assigned education and updates.
Maintain reliable attendance and availability in accordance with established policies and the requirements of a remote work environment.
Perform other job-related duties as assigned.