Senior Pharmacy Claims Auditor

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $59k - $94k / year

⏰ Full Time

🟠 Senior

🔎 Auditor

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

Prime Therapeutics

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1998

🏥 Healthcare

💼 Consulting

🛡️ Insurance

Healthcare • Consulting • Insurance

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

• Provide education, training, and guidance to identify and evaluate potential waste and compliance through the pharmacy audit process • Lead development and enhancement of audit tools, analytics, processes, and training • Identify erroneous claims, non-compliant pharmacy practices, and potential improper pharmacy reimbursements • Execute and support audit-related initiatives using best practices • Identify emerging audit trends and uncover business value opportunities for Prime and its clients • Collaborate with cross-functional teams on training focused on trend analysis, audit planning, procedures, and system processes • Identify technology enhancement opportunities • Provide guidance and operational support to the Pharmacy Audit Operations team • Promote best practices, lead projects, and resolve issues • Analyze claim and audit data to support audit analytics and identify trends and refinements • Collaborate with department staff to create enhanced reporting • Represent the audit team as subject matter expert for system enhancement initiatives and testing • Perform 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 • 5 years of work experience in retail, long-term care, specialty, home infusion, or mail order pharmacy, or combined pharmacy and Pharmacy Benefit Management experience • 3 years of work experience in audit or quality assurance • National Pharmacy Technician Certification through PTCB or ExCPT (CPhT) • Must be eligible to work in the United States without the need for work visa or residency sponsorship • Ability to adjust direction based on changing priorities and business needs while working autonomously • Ability to think critically, solve problems, use appropriate judgment, make decisions, and provide risk advice • Ability to establish trust, respect, and credibility and form effective working relationships • Ability to collaborate cross-functionally with clients and stakeholders • Ability to distill complex concepts into concise communications • Ability to de-escalate potentially confrontational situations • Proficiency in MS Word, Excel, and database software • Understanding of point-of-sale and online pharmacy claims processing environments • Preferred: 5 years of previous audit experience • Preferred: Current registration with the State Board of Pharmacy in the state where the position is located • Preferred: Previous PBM experience • Must comply with job-specific security responsibilities, legal, regulatory, contractual, and internal policy requirements • Must be able to perform essential job functions, with reasonable accommodations as applicable

🏖️ Benefits

• Benefits, incentives and additional compensation are available through Prime’s Benefits Page • Reasonable accommodations for employees with disabilities • Tobacco-Free Workplace