Pharmacy Claims Auditor
New
P
Prime TherapeuticsPharmacy Benefit Management
United StatesFull-TimeMiddle
Salary25.48 - 40.87 USD per hour
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Job Details
- Experience
- 2 years of work experience in pharmacy; 1 year of work experience in an operations, audit or quality assurance environment
- Required Skills
- Data AnalysisMicrosoft ExcelCompliance
Requirements
- Bachelor’s degree in Health Science 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.
- 1 year of work experience in an operations, audit or quality assurance environment.
- National Pharmacy Technician Certification through PTCB or ExCPT (CPhT).
- Proficiency in MS Word, Excel, and database software.
- Intermediate skill and understanding of the point of sale and on-line pharmacy claims processing environment.
- Ability to think critically and use appropriate judgement.
- Ability to collaborate cross-functionally and with external stakeholders.
- Strong communication skills with the ability to distill complex situations.
Responsibilities
- Conduct in-depth analysis of large datasets and audit findings to detect high-risk pharmacy claims and billing irregularities.
- Research and select appropriate audit samples strategically, prioritizing claims based on risk indicators.
- Evaluate pharmacy claims and supporting documentation against contractual terms and state/federal regulations.
- Educate pharmacies on documentation standards and compliance best practices.
- Support audit-related projects and identify trends or business value opportunities.
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