Sr Pharmacy Claims Auditor

Job Title

Pharmacy Claims Auditor Sr - Remote

Job Summary

The Senior Pharmacy Claims Auditor is responsible for providing education, training and guidance to identify and evaluating potential waste and compliance through the pharmacy audit process. This position leads the development and enhancement of audit tools, analytics, processes, and training to effectively identify erroneous claims, non-compliant pharmacy practices or potential improper pharmacy reimbursements. This role will execute and support audit-related initiatives, leveraging best practices to identify emerging audit trends and uncover business value opportunities for Prime and its clients.

Responsibilities

• Collaborate with cross-functional teams to identify, develop, deliver, and support training focused on trend analysis, audit planning, procedures, and system process, along with identifying technology enhancement opportunities

• Provide guidance and operational support to the Pharmacy Audit Operations team, promoting best practices, leading projects, and resolving issues

• Analyze claim and audit data to support ongoing audit analytic efforts, identify trends and refinements; collaborate with other department staff to create enhanced reporting and represent audit team as the Subject Matter Expert (SME) for system enhancement initiatives and testing

• Other duties as assigned

  Minimum Qualifications

• Bachelors degree in Health Science or related area of study, or equivalent combination of education and related work experience; HS diploma or GED is 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 to include 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

  Additional Qualifications

• Change agile; willing and able 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 make decisions and provide risk advice to internal and external partners while anticipating the broad impact of decisions

• Ability to establish trust, respect and credibility and form effective working relationships with individuals at all levels of an organization; collaborate effectively cross-functionally and with clients and other key stakeholders

• Ability to distill complex concepts or situations into concise and compelling communications

• Ability to effectively de-escalate potentially confrontational situations

• Proficiency in MS Word, Excel, and database software

• Demonstrated skill and understanding of the point of sale and on-line pharmacy claims processing environment

  Preferred Qualifications

• 5 years of previous audit experience

• Current Registration with State Board of Pharmacy in the state where position is located

• Previous PBM experience

Disclaimer: This job posting and Location has been aggregated from external source. Role details, content, and availability are subject to change. Applicants are advised to confirm the latest information directly on the company website before applying.