Claims Audit Specialist

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

Claims Audit Specialist

Job Description

The Claims Audit Specialist contributes to the integrity of PBM claims auditing programs by reviewing and analyzing pharmacy insurance claims. This role ensures the accurate application of client-specific benefits and verifies appropriate reimbursement according to contractual agreements. The position is responsible for researching, resolving, and reporting all identified discrepancies, actively driving the timely correction of claims issues.

Responsibilities

• Conduct routine pharmacy claim audits, reviewing adjudicated claims to ensure accuracy and compliance with client benefit structures and contracts
• Research and analyze identified claim discrepancies and errors, document, and initiate necessary corrective actions
• Support account teams, benefit configuration, and other internal departments to resolve identified errors and facilitate timely claim corrections
• Review and interpret client benefit plans, verifying accurate application to claims adjudication processes and identifying potential inconsistencies
• Participate in focused pharmacy claim audits and special projects, applying audit criteria to support departmental objectives
• Prepare and create pharmacy claim audit reports on a regular basis (monthly and quarterly), summarizing findings and resolution statuses
• Other duties as assigned

​

Minimum Qualifications

• High school diploma from an accredited school or equivalent GED

​

Must be eligible to work in the United States without the need for work visa or residency sponsorship

Additional Qualifications

• Ability to interpret complex pharmacy plan benefits, understand, and apply accurate payment determinations
• Ability to understand the contracts, business, and insurance principles related to the claims adjudication process
• Knowledge of coordination of benefit guidelines and an understanding of the adjustment and resolution process
• Ability to function independently with strong organizational, interpersonal, verbal, and written communication skills
• Ability to deliver work in a timely manner
• Ability to adapt in an ever-changing environment

Preferred Qualifications

• Associate's degree in business or healthcare
• PBM, Pharmacy, or health care experience
• CPhT certification
• Data validation claims audit experience
• Experience with multiple claim processing systems

​

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 $19.23 - $28.85 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.