Pharmacy Claims Auditor

Eagan, Minnesota
Apply for details
Mar 15, 2019
Job Type
Full Time

The Pharmacy Claims Auditor is responsible for monitoring the contractual and regulatory obligations of Prime’s network pharmacies by performing daily or periodic claims reviews. This position is responsible for  educating Prime’s network pharmacies and driving contract compliance through the regular review of outlier reports, downstream collection/adjustment activities and, in collaboration with the Special Investigations Unit (SIU), investigating potential fraud, waste, and abuse (FWA).  The Pharmacy Claims Auditor assists in the development and enhancement of audit tools and processes to effectively identify erroneous claims, non-compliant pharmacy practices or potential pharmacy reimbursements. 






  • Assess participating Network Pharmacies compliance against contractual and regulatory obligations through the review daily claims
  • Solicit documentation to support claim activity by conducting telephonic, fax or email outreach to pharmacies; proactively communicate and follow up with pharmacies to drive timely and accurate documentation receipt and review
  • Analyze pharmacy claims to identify those at the highest risk for error; select claims for audit in alignment to department procedures and objectives
  • Educate external pharmacy staff on proper submission of on-line transactions and the use of Prime Therapeutics’ Pharmacy Provider Manual at all stages of the audit process
  • Identify opportunities to improve daily audit processes and drive efficiency and innovation; collaborate with department staff, the training and QA team, and department leadership to develop and implement new or enhanced practices
  • Identify and escalate potential non-compliant, suspicious, or fraudulent pharmacy activity to management and/or Prime’s SIU for further investigation and review
  • Adhere to audit completion turnaround times, quality metrics, and other performance indicators established within Pharmacy Audit; Track audit activities to support data analysis and reporting efforts within the department
  • May obtain and review pharmacy documentation as requested for government audits
  • Other duties as assigned



Minimum Qualifications


  • High school diploma from an accredited school or equivalent GED is required
  • National Pharmacy Technician Certification through PTCB or ExCPT (CPhT)
  • Current Registration with State Board of Pharmacy in the state where position is located
  • 2 years of experience in retail, long term care, specialty, home infusion, or mail order pharmacy or combined pharmacy and PBM experience
  • Previous experience in an operations, audit or quality assurance environment
  • Must be eligible to work in the United States without 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


  • Bachelor’s degree in related field of study
  • 3 years previous audit experience
  • Previous PBM experience 



Minimum Physical Job Requirements


  • Ability to work a flexible schedule including weekends, holidays, or shifts outside of Prime’s core business hours of 9:00am-4:00pm
  • Frequently required to sit, use hands to handle or feel, talk and hear
  • Frequently required to stand, use hands to handle or feel, talk and hear
  • Frequently required to reach with hands and arms
  • Occasionally required to stand, walk and stoop, kneel, and crouch
  • Occasionally required to lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds
  • Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus



Reporting Structure


  • Reports to Manager Pharmacy Audit in the Pharmacy Audit and FWA department



Prime Therapeutics LLC is an Equal Opportunity Employer. We encourage qualified minority, female, veteran, disabled, and other diverse candidates to apply and be considered for open positions.