Pharmacy Claims Auditor Sr - 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 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

• Bachelor's 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

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.

To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits at a glance" button for more detail (

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.

Originally posted on Himalayas