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 TitlePharmacy Claims Auditor Sr - RemoteJob DescriptionThe 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.
Potential pay for this position ranges from $59,000.00 - $94,000.00 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 (https://www.primetherapeutics.com/benefits).
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.
Skills Required
- Bachelor’s degree in Health Science or a related field, or an equivalent combination of education and related work experience; high school diploma or GED required.
- Five years of experience in retail, long-term care, specialty, home infusion, or mail-order pharmacy, or combined pharmacy and Pharmacy Benefit Management experience, including three years in audit or quality assurance.
- National Pharmacy Technician Certification through PTCB or ExCPT (CPhT).
- Eligible to work in the United States without work visa or residency sponsorship.
- Proficiency in Microsoft Word, Microsoft Excel, and database software.
- Demonstrated understanding of point-of-sale and online pharmacy claims processing environments.
- Five years of previous audit experience.
- Current registration with the State Board of Pharmacy in the state where the position is located.
- Previous Pharmacy Benefit Management experience.
Prime Therapeutics Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about Prime Therapeutics and has not been reviewed or approved by Prime Therapeutics.
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Healthcare Strength — Health coverage is described as comprehensive, with medical, dental, and vision options and plan designs that include low deductibles for some choices. Wellness screenings and related incentives add perceived value to the health offering.
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Retirement Support — Retirement benefits stand out through a 401(k) match that is characterized as generous and immediately vested. This structure improves the overall long-term value of the total rewards package.
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Strong & Reliable Incentives — Annual incentive bonuses are positioned as a meaningful component of total compensation and are often portrayed as substantial when performance goals are met. Incentive eligibility appears broadly available across roles, boosting the perceived completeness of rewards.
Prime Therapeutics Insights
What We Do
Everything we do is connected to helping people get the medicine they need to feel better and live well. It’s meaningful work and we’ve been doing it for over 20 years. In the pharmacy benefit management (PBM)industry, we’re different. We’re owned by 18 not-for-profit Blue Cross and Blue Shield health plans. This allows us to control costs and empower our employees to put members first. It’s a successful combination. We have the lowest pharmacy trend in the industry and serve 28+ million members throughout the US. In addition to core PBM services, we work closely with our clients to implement the right benefit design, clinical and specialty programs, formulary and networks. A few key products: • NetResults™ • Specialty Drug Management • Best in Care™ • GuidedHealth® • Advanced Fraud, Waste and Abuse: Member and Prescriber Investigations • Prime Analytics™ • CareCentered Contracting™Controlled Substance Management Program Join us! Prime is always looking for smart, purposeful people to join our team. We’re growing fast which means there are plenty of opportunities to advance and grow in your career. At the same time, Prime supports flexibility and offers generous PTO so you can enjoy an enviable work/life balance. We’re a privately held company -big enough to make a difference and small enough for you to have an impact. Follow Prime on LinkedIn to learn more.
