Pharmacy Claims Auditor (Remote)

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.