Claims Quality Auditor jobs in Pittsburgh, PA

This is an opportunity for a motivated individual who likes to work in a “can do” environment. Client commitments are the driving force of this company, which means that we’re looking for people who think through issues from a client’s point of view, who are willing to put in extra effort, when needed, are sensitive to deadlines and committed to high-quality end product, and who take ownership of their work.

General Background

Fast growing medical claims auditing firm, located in downtown Pittsburgh, PA, that performs a comprehensive series of electronic audits and reviews designed to identify various claim payment error conditions for on-site analysis and validation. This is an opportunity for a very motivated individual who wants to grow in responsibility and who likes to work in a “can do” environment. Client commitments are the driving force of this company, which means that we’re looking for people who think through issues from a client’s point of view, who are willing to put in an extra effort when needed and who are sensitive to deadlines and high quality end product (i.e., take ownership)

Overview of Work Parameters

Medical and pharmacy benefit claims auditing firm that performs a comprehensive series of electronic audits and manual reviews of the administration of medical and pharmacy benefit claims. The process is designed to identify various claim payment error conditions for on-site analysis and validation of identified payment errors. The overall objectives include the identification of systemic and non-systemic claims administrative weaknesses for corrective action and the identification of specific payment exceptions for potential recovery. The audit criteria are based upon preset programming logic and includes the identification of payment exceptions for eligibility, coordination of benefits, Medicare coordination, Medicare ESRD, other party liability, medical correct coding, technical correct coding, plan benefit and contract compliance. Programming changes are required to meet each client’s specific needs.

Pharmacy Benefit Claims Auditor

The Pharmacy Benefit Claims Auditor position involves reviewing pharmacy benefit plans, working with an IT department to develop or amend programming logic to reflect different plan designs, reviewing computer printouts of erroneously paid claims, reviewing contract compliance provisions of pharmacy benefit management and pharmacy benefit plan limitations, selecting claims for on-site review at the claims administrator, participating in the on-site review of claims and developing and finalizing reports to reflect validated audit findings.

Minimum Job Requirements

Several years experience in the pharmacy benefit administration or pharmacy benefit claims processing industry or; the adjusting of pharmacy benefit claims or; having worked five or more years in the pharmacy benefit management of an insurance department, or human resource department of a large employer responsible for the oversight of pharmacy benefits paid by an outside administrator or; the internal audit area of a larger employer responsible for the review and audit of pharmacy benefit claim payments by an outside administrator. Must be able to understand how specific pharmacy benefit plans are to be administered by reviewing the plan sponsor’s Summary Plan Descriptions and/or Benefit Booklets. Good oral and written communication skills are required. The position requires interaction with internal staff, corporate clients and pharmacy benefit administrators. Computer skills such as knowledge of Excel, Word and Access is required. Prior claims audit experience would be a beneficial. Knowledge and understanding of pharmacy benefit plans and/or knowledge of provider discount contracts and arrangements would also be beneficial. The position may require the ability to travel several times per year, generally involving three to five days away from the company headquarters in Pittsburgh, PA.