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Independence Blue Cross · 1 month ago

Pharmacy Claims Auditor (Remote - PA, NJ, and DE)

United States

Full-time

Remote

Mid Level

4+ years exp

Independence Blue Cross is seeking a Pharmacy Claims Auditor to enhance the health and well-being of the communities they serve. The role involves conducting pharmacy claim audits to ensure accurate provider payments and detect fraud, waste, or abuse, while also improving audit processes.

Health CareHealth InsuranceInsuranceMedical

Responsibilities

Conduct audits of claims submitted to Independence Blue Cross (IBX) to ensure accuracy of provider payments and charges

Analyze provider billing patterns to detect potential fraud, waste, or abuse

Perform audits through daily reviews, live audits, and desk audits to identify inappropriate billing practices

Review and verify provider billing records, collaborating with CFID audit analysts, auditors, investigators, internal, and external sectors

Execute standard provider audit assignments using sound audit methodologies to uncover patterns of abuse or fraud

Screen and audit claim samples—both summary and detailed—to select cases for further review

Initiate and validate claim adjustments, maintain comprehensive audit documentation, and prepare statistical reports

Identify and escalate potential provider fraud or abuse to management

Contribute to the development and implementation of new audit processes and functions

Qualification

Certified Pharmacy TechnicianPharmacy audit experienceHealthcare provider audit practicesFraud detection methodologiesMicrosoft Office proficiencyAdvanced Excel skillsPharmacy claims systemsCommunication skills