Pharmacy Claims Auditor
Job 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
Requirements:
• Bachelor’s degree in Health Science or related area of study, or equivalent combination of education and related work experience
• 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
Benefits:
• Health insurance
• 401(k) matching
• Flexible work hours
• Paid time off
• Remote work options
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Apply To this Job
• 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
Requirements:
• Bachelor’s degree in Health Science or related area of study, or equivalent combination of education and related work experience
• 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
Benefits:
• Health insurance
• 401(k) matching
• Flexible work hours
• Paid time off
• Remote work options
Apply tot his job
Apply To this Job