Sr Pharmacy Claims Auditor
Prime Therapeutics · Remote · remote · Posted 49d ago
Undisclosed5–10 yrsfulltimeSourced from
About a minute. You'll make an account on the way through.
About this role
Job Title
Job Summary
Responsibilities
Minimum Qualifications
Additional Qualifications
Preferred Qualifications
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.
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.
Sourced from naukri
Skills
retailAgilesubject matter expertoperational supportsecurity controlsaudit toolsAnalyticsPharmacypharmacy technicianQuality AssuranceoperationsAudit PlanningLegalWordcomplianceClaims Processingtechnician
About Prime Therapeutics
Prime Therapeutics
Eagan
US
About
Prime Therapeutics is a pharmacy benefit management company that partners with health plans, employers, and government programs to provide cost-effective prescription drug services. It focuses on improving patient outcomes by managing medication access, affordability, and adherence. Through integrated solutions and collaborative care, Prime Therapeutics helps millions of members optimize their pharmacy benefits while reducing overall healthcare costs.
Industries
Health CarePharmaceutical
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