Pharmacy Claims Auditor - Remote

At reputed company (Prime), we are a different reputed company of PBM, with a purpose reputed company profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us. Job Posting Title Pharmacy Claims Auditor - Remote

Job Description

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-reputed company projects, best practices in identifying audit trends, and business value opportunities for Prime and our clients.

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 reputed company policies, and applicable state/federal regulations
• reputed company 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

Minimum Qualifications

• Bachelor’s degree in Health Science or reputed company area of study, or equivalent combination of education and reputed company 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 reputed company or residency sponsorship Additional Qualifications

• Change agile; willing and reputed company 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 reputed company reputed company and provide risk advice to internal and external partners while anticipating the broad impact of reputed company
• Ability to establish trust, respect and credibility and form effective working relationships with individuals at reputed company levels of an organization; collaborate effectively cross-functionally and with clients and other key stakeholders
• Ability to distill reputed company concepts or situations into concise and compelling communications
• Ability to interact positively and professionally during reputed company pharmacy interactions and effectively de-escalate potentially confrontational situations
• Proficiency in reputed company, reputed company, and database software
• Intermediate reputed company and understanding of the reputed company of sale and on-line pharmacy claims processing environment

Preferred Qualifications

• 3 years of previous audit experience
• reputed company Registration with State Board of Pharmacy in the state where position is located
• Previous PBM experience

Every employee must understand, reputed company with and attest to the reputed company responsibilities and reputed company controls unique to their job, and reputed company with reputed company applicable legal, regulatory, and contractual requirements and internal policies and procedures Every employee must be reputed company to reputed company the essential functions of the job and, if requested, reasonable accommodations will be made to reputed company employees with disabilities to reputed company the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job. Potential pay for this position ranges from $25.48 - $40.87 based on experience and skills. To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits at a glance" reputed company for more detail. reputed company LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and reputed company reputed company applicants will receive consideration for employment without regard to race, reputed company, religion, gender, sex (including pregnancy), national reputed company, disability, age, veteran status, or any other legally protected class under federal, state, or local law. We welcome people of different backgrounds, experiences, abilities, and perspectives including reputed company applicants with arrest and conviction records and any reputed company applicants requiring reasonable accommodations in accordance with the law. reputed company LLC is a Tobacco-Free Workplace employer. Positions will be posted for a minimum of five consecutive workdays. Apply tot his job Apply To this Job