Pharmacy Claims Auditor

🔥 1 hour ago

🇺🇸 United States – Remote

💵 $25 - $40 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

🔎 Auditor

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Prime Therapeutics

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1998

⚕️ Healthcare Insurance

💊 Pharmaceuticals

☁️ SaaS

Healthcare Insurance • Pharmaceuticals • SaaS

Prime Therapeutics is a trusted pharmacy solutions provider dedicated to transforming health care through innovation and transparency. The company offers a wide range of services including clinical solutions for improved member outcomes, drug access and affordability, specialty drug management, and condition management for chronic health issues. With over 7,000 employees, Prime Therapeutics aims to challenge norms in the pharmacy industry, providing exceptional experiences and simplifying the complex for millions across the nation. Their mission goes beyond profit, focusing on creating transformative impacts with long-term solutions, utilizing modern technology and holistic approaches in specialty pharmacy management. Owned by mission-driven partners, Prime Therapeutics emphasizes true transparency and conflict-free service, fostering a culture of care and shared purpose in health care.

📋 Description

• Conduct in-depth analysis of large datasets and audit findings to detect high-risk pharmacy claims, identify billing irregularities, and uncover patterns 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

🎯 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

🏖️ Benefits

• Health insurance • 401(k) matching • Paid time off • Flexible work arrangements