Pharmacy Claims Auditor - Remote

Job Description:

Pharmacy Claims Auditor - Remote

The Pharmacy Claims Auditor is responsible for the selection and auditing of claims, educating Prime’s network pharmacies and driving contract compliance, and supporting downstream claim corrections and eliminate potential waste.

Responsibilities

• Validate claim documentation and systems data to ensure claim was accurately processed in accordance with contractual and regulatory obligations
• Solicit documentation to support pharmacy claim submission by conducting telephonic, fax or email outreach to pharmacies
• Proactively communicate and follow up with pharmacies to drive timely and accurate documentation receipt and review
• Analyze pharmacy claims to identify those at the highest risk for error; utilize analytics and professional knowledge to select claims or pharmacies for audit in alignment with department procedures and objectives Educate participating pharmacies on Prime’s billing requirements and appropriate billing practices in alignment with Prime Therapeutics’ Pharmacy Provider Manual
• Based on audit outcome, work directly with pharmacy or internal partners to support accurate data and financial reimbursement to ensure appropriate reversal or correction of claim is performed
• Other duties as assigned

Minimum Qualifications

• Bachelor’s degree in Health Science or related area of study, or equivalent combination of education and related work experience; HS diploma or GED required
• National Pharmacy Technician Certification through PTCB or ExCPT (CPhT)
• 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
• Must be eligible to work in the United States without need for work visa or residency sponsorship

Additional Qualifications

• Proficiency in MS Word, Excel, and database software
• Intermediate skill and understanding of the point of sale and on-line pharmacy claims processing environment
• Excellent oral, written and interpersonal communication skills
• Self-directed worker with excellent organization and analytical skills
• Ability to work effectively with a variety of audiences at all levels of the organization
• Ability to maintain confidentiality of highly sensitive information
• Professional appearance, demeanor, and conflict resolution skills

Preferred Qualifications

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

Minimum Physical Job Requirements

• Ability to work a flexible schedule including weekends, holidays, or shifts outside of Prime’s core business hours of 9:00am-4:00pm
• Frequently required to sit, use hands to handle or feel, talk and hear
• Frequently required to stand, use hands to handle or feel, talk and hear
• Frequently required to reach with hands and arms
• Occasionally required to stand, walk and stoop, kneel, and crouch
• Occasionally required to lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds
• Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus

Reporting Structure

• Reports to a Manager in the Pharmacy Audit and FWA department