Top 22 pharmacy claims auditor Jobs in remote

Medical Claims Auditor
WellSense Health Plan —Remote
- $57,500 - $83,500 a year
- Full-time
- Background check
- Nursing
- RN License
- Health insurance
- Dental insurance
SME - Medicaid Program Integrity and Claims Audits
BerryDunn —Remote
- $120,000 - $140,000 a year
- Full-time
- Bachelor of Science
- Research
- Analysis skills
- Dental insurance
Claims Quality Assurance
CorVel Corporation —San Diego, CA
- $70,304 - $116,942 a year
- Full-time
- Remote
- Analysis skills
- Bachelor's degree
- Mentoring
- Health savings account
- Disability insurance
Quick Apply
Senior Pharmacy Audit Analyst
Vital Care Infusion Services —Remote
- $59,838 - $75,255 a year
- Full-time
- Remote
- Microsoft Excel
- Microsoft Outlook
- Office
- Health savings account
- Paid holidays
Quick Apply
Pharmacy Claims Auditor (Remote)
Independence Blue Cross —Philadelphia, PA
- Remote
- Microsoft Outlook
- Mid-level
- Analysis skills
6d
Medical Claim Auditor
Gallagher Benefit Services —Rolling Meadows, IL
- $67,500 - $131,500 a year
- Full-time
- Remote
- 5 years
- HIPAA
- SQL
- Paid parental leave
- Health savings account
11d
Claims Training Specialist
CorVel Corporation —Folsom, CA
- $77,960 - $120,368 a year
- Full-time
- Remote
- Classroom
- Computer literacy
- HIPAA
- Health savings account
- Disability insurance
Quick Apply
Auditor of Pharmacy Benefit Management
Gallagher Benefit Services —Rolling Meadows, IL
- $67,500 - $131,500 a year
- Full-time
- Remote
- Microsoft Excel
- Microsoft Outlook
- 5 years
- Paid parental leave
- Health savings account
340B Program Coordinator
MAYERS MEMORIAL HOSPITAL DISTRICT —Remote
- $24.00 - $29.56 an hour
- Full-time
- Mid-level
- 3 years
- High school diploma or GED
5d
Lead Audit Specialist - Remote
EmblemHealth —New York, NY
- $77,760 - $149,040 a year
- Remote
- Microsoft Excel
- Microsoft Outlook
- 5 years
SIU & Payment Integrity AI Analyst
Codoxo —Duluth, GA
- Temporary
- Remote
- 5 years
- Senior level
- Leadership
Quick Apply
CDI Team Lead
Boston Medical Center —Remote
- $89,500 - $130,000 a year
- Full-time
- Nursing
- Microsoft Excel
- Microsoft Outlook
- Health insurance
- Dental insurance
National Coding Educator - Remote
Optum —Irvine, CA
- $91,700 - $163,700 a year
- Full-time
- Remote
- Up to 50% travel
- Pass drug screening
- Mid-level
14d
DRG/Clinical Validation Auditor RN
Optum —Plymouth, MN
- $34.23 - $61.15 an hour
- Full-time
- Remote
- Nursing
- Anatomy knowledge
- RN License
- AD&D insurance
- Employee stock purchase plan
Quality Assurance Nurse
CorVel Corporation —Folsom, CA
- $70,304 - $98,334 a year
- Full-time
- Remote
- Nursing
- Microsoft Excel
- RN License
- Health savings account
- Disability insurance
Quick Apply
Sr Manager, Managed Care Rebate Integrity & Controls
Fresenius Kabi —Remote
- $140,000 - $165,000 a year
- Full-time
- Office
- Finance
- Analysis skills
- Wellness program
- Health insurance
Hybrid Pharmacist - 4 Days Retail/1 Day Remote (MO)
Walgreens —Remote
- Hybrid work
- Bachelor of Science
- Mid-level
- Organizational skills
- Paid parental leave
- Health insurance
Hybrid Pharmacist - 4 Days Retail/1 Day Remote (NC)
Walgreens —Remote
- Hybrid work
- Bachelor of Science
- Mid-level
- Organizational skills
- Paid parental leave
- Health insurance
Hybrid Pharmacist - 4 Days Retail/1 Day Remote (TN)
Walgreens —Remote
- Hybrid work
- Bachelor of Science
- Mid-level
- Organizational skills
- Paid parental leave
- Health insurance

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Based on your search for pharmacy claims auditor jobs.

Lead Claims Auditor
Bellwether Staffing Solutions —Remote
Degree in law, risk management, or a related field; required - J.D. highly desired. Manage and maintain 50-state claims database.
$130,000 - $160,000 a year
Quick Apply
3d
Claims Auditor - DRG
Cohere Health —Remote
RHIA, or RHIT credential, Associate's Degree in Health Information Management, Nursing, or related field. In accordance with state applicable laws, Cohere is…
$72,000 - $82,000 a year
Quick Apply

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pharmacy claims auditor jobs near remote

Medical Claims Auditor

WellSense Health Plan -
Remote

Apply Now

Job Details

Full-time
$57,500 - $83,500 a year

Benefits

Health insurance
Dental insurance
Flexible spending account
Paid time off
Vision insurance
403(b)
Opportunities for advancement

Qualifications

Nursing
Nursing

Full Job Description

It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

The Medical Claims Auditor manages the process by which claims failing established clinical-related adjudication parameters are evaluated for payment. Leveraging clinical and/or coding expertise in the performance of the key functions of the position. The MCA considers a variety of factors including, but not limited to, Plan benefit, reimbursement and medical policies, provider contracts, correct coding guidelines, and adequacy of documentation of the service in question, whether the activity is the analysis of claims having failed the adjudication process for clinical/coding-related reasons or is the verification that services billed and paid were documented as having been provided.

Our Investment in You:

Full-time remote work

Competitive salaries

Excellent benefits

Key Functions/Responsibilities:

Analyzes claims that have failed established clinical -related adjudication parameters by applying knowledge of CPT, HCPCS and ICD 10.

Establishes root cause of claims failure and applies Plan benefit, reimbursement and/or medical policies, contract terms, etc. to determine the appropriate resolution.

Prioritizes claims/cases based on urgency

Consults staff in the Office of Affairs (OCA), Business Integration, Claims, Legal, claims, Benefits, Payment Policy, and other departments, as necessary, to resolve atypical issues.

Acts as internal consultant to various internal departments, such as Customer Care and Provider Relations, regarding clinical/coding-related adjudication parameters and their application in specific cases

Applies, during the assigned clinical audits, knowledge of CPT, HCPCS, ICD10, provider contract terms, and Plan clinical and reimbursement policies to the validation of services in the medical record, and the accuracy of payment.

Documents clinical audit findings and communicates them to provider’s; records final audit findings and, where appropriate, processes recoveries or payments.

Identifies, during the analysis of failed claims or clinical audits, potential deficiencies in the delivery of care and refers to the appropriate department.

Identifies opportunities to improve or streamline clinical/coding-related adjudication parameters and/or their effect on claims processing and escalates to management for review and communication.

Maintains established productivity and quality metrics.

Other duties as assigned

Supervision Exercised:

Provides technical assistance to less experienced staff members

Supervision Received:

Indirect supervision is received weekly

Qualifications:

Education:

Bachelor's degree in Nursing with certification in coding either through AAPC or AHIMA or the equivalent combination of Coding Certification through AAPC or AHIMA, education, training and experience

Experience:

If a Registered Nurse:

o Minimum one year medical claim auditing or medical record review and Coding certification in AAPC or AHIMA

o Minimum two years RN experience in a clinical setting

If a Certified Coder:

o Minimum seven years direct coding experience

Preferred/Desirable:

Two years’ experience in health care insurance, or provider coding or claims processing settings

Certification or Conditions of Employment:

Successful completion of pre-employment background check

Valid MA or NH Registered Nurse license or eligible OR valid AAPC or AHIMA coding certification

Competencies, Skills, and Attributes:

Proficiency in the use of Facets claim processing system

Strong oral and written communication skills

A strong working knowledge of Microsoft Office and Excel products

Demonstrated ability to successfully organize and manage projects

Ability to interact within all levels of the organization and external contacts

Must be team and detail oriented with strong analytical and problem solving skills and able to work in a fast-paced environment

Works independently without the need to assign tasks/self-motivated

Proven ability to maintain confidentiality

Working Conditions and Physical Effort:

Regular and reliable attendance is an essential function of the position.

Very limited physical effort required. Occasional bending and lifting up to 30 lbs.

No or very limited exposure to physical risk.

Ability to work during peak periods.

Compensation Range

$57,500- $83,500

This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, WellSense offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.

Note: This range is based on Boston-area data, and is subject to modification based on geographic location.

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees

Apply Now

Refine Your Search

pharmacy claims auditor jobs in remote

Medical Claims Auditor

SME - Medicaid Program Integrity and Claims Audits

Claims Quality Assurance

Senior Pharmacy Audit Analyst

Pharmacy Claims Auditor (Remote)

Medical Claim Auditor

Claims Training Specialist

Auditor of Pharmacy Benefit Management

340B Program Coordinator

Lead Audit Specialist - Remote

SIU & Payment Integrity AI Analyst

CDI Team Lead

National Coding Educator - Remote

DRG/Clinical Validation Auditor RN

Quality Assurance Nurse

Sr Manager, Managed Care Rebate Integrity & Controls

Hybrid Pharmacist - 4 Days Retail/1 Day Remote (MO)

Hybrid Pharmacist - 4 Days Retail/1 Day Remote (NC)

Hybrid Pharmacist - 4 Days Retail/1 Day Remote (TN)

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