Pharmacy Claims Auditor - Remote
Prime Therapeutics, Denver, CO, United States
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.
Pharmacy Claims Auditor – Remote
Job Description
The Pharmacy Claims Auditor is responsible for identifying and evaluating potential waste and compliance through the pharmacy audit process and for educating Prime’s network pharmacies and driving contract compliance. The position researches, analyzes, and compiles supporting information, executes and supports audit‑related projects, identifies audit trends, and uncovers business value opportunities for Prime and its clients.
Responsibilities
Conduct in‑depth analysis of large datasets and audit findings to detect high‑risk pharmacy claims, identify billing irregularities, and uncover patterns of non‑compliance or systemic errors.
Research and select appropriate audit samples strategically, and 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 an equivalent combination of education and work experience; high school diploma or GED required.
Two years of work experience in retail, long‑term care, specialty, home infusion, or mail order pharmacy, or combined pharmacy and Pharmacy Benefit Management experience that includes at least one year of work experience in an operations, audit, or quality assurance environment.
National Pharmacy Technician Certification through PTCB, ExCPT (CPhT).
Additional Qualifications
Change agile; willing and able to adjust individual and team direction based upon changing priorities and business needs while working with a high degree of autonomy.
Ability to think critically, problem‑solve, and use appropriate judgment 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 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 online pharmacy claims processing environment.
Preferred Qualifications
Three years of previous audit experience.
Current registration with the State Board of Pharmacy in the state where you live.
Previous PBM experience.
Previous Retail Pharmacy Technician 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 $25.48 – $40.87 based on experience and skills.
Prime Therapeutics LLC is a Tobacco‑Free Workplace employer.
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.
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 1.866.469.1257 or email Careers@primetherapeutics.com.
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Pharmacy Claims Auditor – Remote
Job Description
The Pharmacy Claims Auditor is responsible for identifying and evaluating potential waste and compliance through the pharmacy audit process and for educating Prime’s network pharmacies and driving contract compliance. The position researches, analyzes, and compiles supporting information, executes and supports audit‑related projects, identifies audit trends, and uncovers business value opportunities for Prime and its clients.
Responsibilities
Conduct in‑depth analysis of large datasets and audit findings to detect high‑risk pharmacy claims, identify billing irregularities, and uncover patterns of non‑compliance or systemic errors.
Research and select appropriate audit samples strategically, and 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 an equivalent combination of education and work experience; high school diploma or GED required.
Two years of work experience in retail, long‑term care, specialty, home infusion, or mail order pharmacy, or combined pharmacy and Pharmacy Benefit Management experience that includes at least one year of work experience in an operations, audit, or quality assurance environment.
National Pharmacy Technician Certification through PTCB, ExCPT (CPhT).
Additional Qualifications
Change agile; willing and able to adjust individual and team direction based upon changing priorities and business needs while working with a high degree of autonomy.
Ability to think critically, problem‑solve, and use appropriate judgment 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 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 online pharmacy claims processing environment.
Preferred Qualifications
Three years of previous audit experience.
Current registration with the State Board of Pharmacy in the state where you live.
Previous PBM experience.
Previous Retail Pharmacy Technician 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 $25.48 – $40.87 based on experience and skills.
Prime Therapeutics LLC is a Tobacco‑Free Workplace employer.
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.
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 1.866.469.1257 or email Careers@primetherapeutics.com.
#J-18808-Ljbffr