Pharmacy Claims Auditor - Remote

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us.

Job Posting Title

Job Description

The Pharmacy Claims Auditor is responsible for identifying and evaluating potential waste and compliance through the pharmacy audit process and educating Prime’s network pharmacies and driving contract compliance. This position will research, analyze and compile supporting information. This role will also execute and support audit-related projects, best practices in identifying audit trends, and business value opportunities for Prime and our clients.

Responsibilities

• Conduct in-depth analysis of large datasets and audit findings to detect high-risk pharmacy claims, identify billing irregularities, and uncover patters 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
• 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; High school diploma or GED required

• 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

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 interact positively and professionally during all pharmacy interactions and effectively de-escalate potentially confrontational situations
• Proficiency in MS Word, Excel, and database software
• Intermediate skill and understanding of the point of sale and on-line pharmacy claims processing environment

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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

Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures

Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job.

Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law.  

We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law.

Prime Therapeutics LLC is a Tobacco-Free Workplace employer.

Positions will be posted for a minimum of five consecutive workdays.