Job Description of a Pharmacy Claims Auditor

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Pharmacy claims auditors are professionals who ensure prescription drug claims are being paid in accordance with a pharmacy's benefits manager contract. They look at claims from a certain period of time, such as two years. Average pharmacy claim auditor salaries in the United States at the time of publication were $38,000, according to Indeed.com.

Duties

  • Pharmacy claims auditors conduct in-store audits to decrease instances of fraud and increase compliance with government regulations. Before performing a claims audit, pharmacy claim auditors typically must contact the pharmacies they are scheduled to visit a few days prior to the visit date. They then request to see data of paid-for prescriptions to review doctors who wrote the prescriptions, pharmacies that filled the prescriptions, pharmacy benefit managers who processed the prescriptions and patients who used the drugs.

Other Responsibilities

  • While reviewing prescription drug claims, pharmacy claims auditors check to see if the correct dispensing fees were applied to a client's claims and if brand-name products were used when a less expensive generic version was available. They also check to see if any products were billed to a client even though they were not covered by his insurance benefits plan.

    After reviewing pharmacy prescriptions during an audit, pharmacy claims auditors use a digital scanner to flag a prescription for a discrepancy in relation to state and federal pharmacy practice parameters. Pharmacy claims auditors then produce detailed reports and pinpoint areas of weakness in pharmacists and their pharmacies. In addition, pharmacy claims auditors put together claims data used in areas such as rebate consulting and rebate reviews.

Skills

  • Pharmacy claims auditors should have a strong knowledge of third-party billing. They additionally must be able to work well independently, be self-motivated and pay strong attention to detail. Strong organizational skills and communication skills as well as the ability to travel about 10 percent of the time also generally is required for pharmacy claim auditors. These professionals additionally should be able to stand for long periods of time when necessary and lift at least 20 pounds.

Experience

  • No formal or specific education requirements exist for pharmacy claims auditors. Employers usually look for pharmacy claims auditors who have a few years of prior experience working in a retail pharmacy as well as a high school diploma or GED. They want job candidates who have basic skills in and an understanding of the point-of-sale pharmacy claims processing environment. Some employers also prefer candidates who are certified pharmacy technicians.

References

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