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, 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

Bachelor’s degree in Health Science or related area of study, or equivalent combination of education and related work experience
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

Pharmacy Claims Auditor

Key skills