Claims Audit Specialist

Job Summary

The Claims Audit Specialist contributes to the integrity of PBM claims auditing programs by reviewing and analyzing pharmacy insurance claims. This role ensures the accurate application of client-specific benefits and verifies appropriate reimbursement according to contractual agreements. The position is responsible for researching, resolving, and reporting all identified discrepancies, actively driving the timely correction of claims issues.

Responsibilities

• Conduct routine pharmacy claim audits, reviewing adjudicated claims to ensure accuracy and compliance with client benefit structures and contracts
• Research and analyze identified claim discrepancies and errors, document, and initiate necessary corrective actions
• Support account teams, benefit configuration, and other internal departments to resolve identified errors and facilitate timely claim corrections
• Review and interpret client benefit plans, verifying accurate application to claims adjudication processes and identifying potential inconsistencies
• Participate in focused pharmacy claim audits and special projects, applying audit criteria to support departmental objectives
• Prepare and create pharmacy claim audit reports on a regular basis (monthly and quarterly), summarizing findings and resolution statuses
• Other duties as assigned

Minimum Qualifications

• High school diploma from an accredited school or equivalent GED
• Must be eligible to work in the United States without the need for work visa or residency sponsorship

Additional Qualifications

• Ability to interpret complex pharmacy plan benefits, understand, and apply accurate payment determinations
• Ability to understand the contracts, business, and insurance principles related to the claims adjudication process
• Knowledge of coordination of benefit guidelines and an understanding of the adjustment and resolution process
• Ability to function independently with strong organizational, interpersonal, verbal, and written communication skills
• Ability to deliver work in a timely manner
• Ability to adapt in an ever-changing environment

Preferred Qualifications

• Associates degree in business or healthcare
• PBM, Pharmacy, or health care experience
• CPhT certification
• Data validation claims audit experience
• Experience with multiple claim processing systems