Claims Auditor

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 Onsite Pharmacy Auditor - Remote (based in Southern California) Job Description The Onsite Pharmacy Auditor travels to pharmacy locations and performs pharmacy audits and is responsible for the selection and auditing of claims, educating Prime's network pharmacies and driving contract compliance, and supporting downstream claim corrections to eliminate potential waste. To best support business needs, we are seeking candidates who reside in Southern California. Responsibilities Evaluate potential pharmacies to include in onsite trips considering such information as claim analytic data, prior audit history, and/or referrals, and submit recommended audit plan to manager for approval; finalize onsite audit plans and schedule trips in accordance to Prime's travel and expense policy Analyze pharmacy claims to identify those at the highest risk for error; leverage audit analytics and professional knowledge to identify educational trends and select claims for audit in alignment to department procedures and objectives Leverage professional pharmacy technician knowledge to validate claim documentation and systems data while onsite to ensure claim was accurately processed in accordance with contractual and regulatory obligations. Educate external pharmacy staff on results of observations of pharmacy practices, proper claim submission and the use of Prime Therapeutics' Pharmacy Provider Manual at all stages of the audit process Assist in the development and enhancement of audit tools and processes to effectively identify erroneous claims, non-compliant pharmacy practices or potential pharmacy reimbursements Track audit activities to support data analysis and reporting efforts within the department Prepare initial audit reports to be sent to the network pharmacies Other duties as assigned Education & Experience Bachelor's degree in Health Science or equivalent combination of education and related work experience; HS diploma or GED is required National Pharmacy Technician Certification through PTCB or ExCPT (CPhT) 2 years of work experience in retail, long term care, specialty, home infusion, or mail order pharmacy or combined pharmacy and PBM experience to include: 2 years of work experience in audit or quality assurance 1 year of work experience in customer service or a client facing role Must be eligible to work in the United States without the need for work visa or residency sponsorship Additional Qualifications Proficiency in MS Word, Excel, and database software Intermediate skill and understanding of the point of sale and on-line pharmacy claims processing environment Excellent oral, written and interpersonal communication skills Self-directed worker with excellent organization and analytical skills Ability to work effectively with a variety of audiences at all levels of the organization Ability to maintain confidentiality of highly sensitive information Professional appearance, demeanor, and conflict resolution skills Preferred Qualifications 3 years previous audit experience Previous experience conducting onsite pharmacy audits 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. Potential pay for this position ranges from $28.37 - $45.19 based on experience and skills. 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 LLCis 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. At Prime Therapeutics (Prime), we are a different kind of PBM. We're reimagining pharmacy solutions to provide the care we would want for our loved ones. That purpose energizes our team and creates limitless opportunities to make a difference. We know that people make all the difference. If you're ready for a purpose-driven career and are passionate about simplifying health care, let's build the future of pharmacy together. Prime Therapeutics LLCis 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 torace, 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. If you are an applicant with a disability and need a reasonable accommodation for any part of the employment process, please contact Human Resources at email View email address on click.appcast.io. #J-18808-Ljbffr