Remote Pharmacy Claims Auditor

About the role

We are seeking a detail‑oriented Pharmacy Claims Auditor to join Independence Blue Cross’s Payment Integrity team. In this fully remote position you will audit pharmacy claims, ensure accurate provider payments, and help detect fraud, waste, or abuse.

Key responsibilities

• Conduct daily, live, and desk audits of pharmacy claims submitted to Independence Blue Cross (IBX).
• Analyze provider billing patterns to identify potential fraud, waste, or abuse.
• Review and verify provider billing records, collaborating with audit analysts, investigators, and internal/external stakeholders.
• Execute standard audit assignments using established methodologies and document findings.
• Screen claim samples, select cases for deeper review, and initiate claim adjustments.
• Prepare statistical reports and maintain comprehensive audit documentation.
• Escalate suspected provider fraud or abuse to management.
• Contribute to the development and implementation of new audit processes.

Required profile

• Certified Pharmacy Technician (CPhT) required.
• Minimum four years of relevant experience, including at least two years in retail or hospital pharmacy and two years in pharmacy audit.
• Strong understanding of healthcare provider audit practices, medical terminology, and fraud detection methodologies.
• Excellent written and verbal communication skills for reporting audit findings.

Required skills

• Proficiency in Microsoft Office applications (Excel, Word, Outlook, SharePoint, Access).
• Advanced Excel skills (pivot tables, VLOOKUP, data analysis).
• Familiarity with pharmacy claims systems such as RxTrack and RxClaim (preferred).