Pharmacy Claims Auditor (Remote)

Auditor, Payment Integrity

Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together, we will achieve our mission to enhance the health and well-being of the people and communities we serve.

The Auditor, Payment Integrity role conducts pharmacy claim audits for Independence Blue Cross to ensure accurate provider payments, detect fraud, waste, or abuse, and improve audit processes. It requires a Certified Pharmacy Technician with at least four years of experience, including pharmacy and audit work, strong analytical skills, and proficiency in Microsoft Office and pharmacy claims systems.

• Conduct audits of claims submitted to Independence Blue Cross (IBX) to ensure accuracy of provider payments and charges.
• Analyze provider billing patterns to detect potential fraud, waste, or abuse.
• Perform audits through daily reviews, live audits, and desk audits to identify inappropriate billing practices.
• Review and verify provider billing records, collaborating with CFID audit analysts, auditors, investigators, internal, and external sectors
• Execute standard provider audit assignments using sound audit methodologies to uncover patterns of abuse or fraud.
• Screen and audit claim samplesboth summary and detailedto select cases for further review.
• Initiate and validate claim adjustments, maintain comprehensive audit documentation, and prepare statistical reports.
• Identify and escalate potential provider fraud or abuse to management.
• Contribute to the development and implementation of new audit processes and functions.

Qualifications Certified Pharmacy Technician (CPhT) required. Minimum of four (4) years of relevant experience, including: At least two (2) years in retail or hospital pharmacy. At least two (2) years in pharmacy audit. Extensive understanding of healthcare provider audit practices and medical terminology. Familiarity with fraud, waste, and abuse detection methodologies. Strong written and verbal communication skills for reporting and presenting audit findings Proficiency in Microsoft Office applications, including Excel, Word, Outlook, SharePoint, and Access. Advanced Excel skills (pivot tables, VLOOKUP, data analysis). Experience with pharmacy claims systems such as RxTrack and RxClaim is preferred but not required.

Fully Remote: This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence's physical office locations to perform the work.

IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.

Must have an Android or iOS device that is compatible with the free Microsoft Authenticator app.