Auditing, Billing, Billing Records, Certified Pharmacy Technician (CPhT), Claims Processing, Communication Skills, Data Analysis, Documentation, Healthcare, Healthcare Providers, Hospital, Medical Terminology, Microsoft Access Database, Microsoft Excel, Microsoft Office, Microsoft Outlook, Microsoft SharePoint, Microsoft Word, Pattern Analysis, Pharmacy, Pivot Tables, Presentation/Verbal Skills, Process Improvement, Reporting Skills, Retail, Statistical Reports, Team Player, Vlookups, Writing Skills
Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together, we will achieve our mission to enhance the health and well-being of the people and communities we serve.
The Auditor, Payment Integrity role conducts pharmacy claim audits for Independence Blue Cross to ensure accurate provider payments, detect fraud, waste, or abuse, and improve audit processes. It requires a Certified Pharmacy Technician with at least four years of experience, including pharmacy and audit work, strong analytical skills, and proficiency in Microsoft Office and pharmacy claims systems.
- 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.
Qualifications
- Certified Pharmacy Technician (CPhT) required.
- Minimum of four (4) years of relevant experience, including:
- At least two (2) years in retail or hospital pharmacy.
- At least two (2) years in pharmacy audit.
- Extensive understanding of healthcare provider audit practices and medical terminology.
- Familiarity with fraud, waste, and abuse detection methodologies.
- Strong written and verbal communication skills for reporting and presenting audit findings
- Proficiency in Microsoft Office applications, including Excel, Word, Outlook, SharePoint, and Access.
- Advanced Excel skills (pivot tables, VLOOKUP, data analysis).
- Experience with pharmacy claims systems such as RxTrack and RxClaim is preferred but not required.
Fully Remote:
This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence's physical office locations to perform the work.
IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.
Must have an Android or iOS device that is compatible with the free Microsoft Authenticator app.
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Blue Cross and Blue Shield Association
At the Blue Cross and Blue Shield Association (BCBSA), we provide business strategy, technical support and consulting expertise to 36 Blue Cross and Blue Shield companies across the nation, employing more than 1,000 of the best strategic thinkers in the industry. We are a Brand manager that sets quality control standards for the 36 independent companies that use the Blue Cross and Blue Shield Brands, and we serve as a trade association that represents these Blue companies. It is through our involvement that the Blues companies share a united vision and strategy while also benefiting from the local strength of all member companies.
2,000 to 2,499 employees
https://www.bcbs.com/about-us/careers