Auditor, Payment Integrity (Remote - PA, NJ, and DE)
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.
Qualifications
• Certified Pharmacy Technician (CPhT) required.
• Minimum of four (4) years of relevant experience, including:
• At least two (2) years in retail or hospital pharmacy.
• At least two (2) years in pharmacy audit.
• Extensive understanding of healthcare provider audit practices and medical terminology.
• Familiarity with fraud, waste, and abuse detection methodologies.
• Strong written and verbal communication skills for reporting and presenting audit findings
• Proficiency in Microsoft Office applications, including Excel, Word, Outlook, SharePoint, and Access.
• Advanced Excel skills (pivot tables, VLOOKUP, data analysis).
• Experience with pharmacy claims systems such as RxTrack and RxClaim is preferred but not required.
Fully Remote:
This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence’s physical office locations to perform the work. However, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania.
IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.
Must have an Android or iOS device that is compatible with the free Microsoft Authenticator app.
Vaccination Update
This job requires that you demonstrate you have been fully vaccinated for COVID-19 prior to the start of employment, to the extent permitted by law.
About Our Company
AmeriHealth Casualty has been successfully returning employees to work since 1994, providing quality medical treatment and care and reducing costs for our customers. With our affiliates, we serve more than 1,800 businesses in the area and have offices in Philadelphia, Camp Hill, and Pittsburgh, PA, and Mount Laurel, NJ.
In 1994, CompServices, Inc. began offering workers’ compensation third-party administration services for manufacturers, municipalities, health care facilities, social services, transportation risk, universities, and retail firms. In 1996, AmeriHealth Casualty Insurance Company was established as an extension of our workers’ compensation claims services — its mission to provide workers’ compensation insurance combined with high quality claims service and cost containment.
AmeriHealth Casualty Insurance Company and CompServices write premiums and administer self-insured programs for over 1,800 customers.
Equal Employment Opportunity
AmeriHealth Casualty is an Equal Opportunity and Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.
Agency Disclaimer
All resumes submitted directly to an AmeriHealth Casualty employee from a vendor via email, the Internet or in any other form without a valid written search agreement in place for this position from the Independence Blue Cross Family of Companies Human Resources Department will be deemed the sole property of AmeriHealth Casualty and the Independence Blue Cross Family of Companies. Please note that no fee will be paid in the event the candidate is hired by AmeriHealth Casualty or the Independence Blue Cross Family of Companies as a result of the referral or through means other than our established process.