Pharmacy Claims Auditor - Retail / Ambulatory (Days)

We’re searching for a Pharmacy Claims Auditor, someone who’s ready to be part of the best ranked children’s hospital in Texas, and among the best in the nation. In this position, you will help oversee the daily operations of pharmacy claims, Pharmacy Benefit Manager (PBM) audits, monitoring pharmacy adjudication trends and team education.

Think you’ve got what it takes?

Job Duties & Responsibilities

• Assists in the operations for the Pharmacy through audit management
• Oversees pharmacy payor directed audits by collecting transactional records and informational data, submitting data by deadlines.
• Maintains audit records to track recovery amounts.
• Ensure PBM auditing processes meet all regulatory and client contractual requirements.
• Provide audit trending report to leaders and internal stakeholders.
• Routine Adjudication Monitoring
• Summarize, report, and communicate key discoveries and audit results to the team and other departments as needed.
• Provides insurance navigation, rejection and technical difficulty education to team.
• Build and maintain relationships with internal business units and pharmacy service providers.
• Performs other essential functions.

As part of our commitment to maintaining a safe and healthy workplace, all successful candidates will be required to undergo respiratory fit testing in compliance with occupational health and safety standards.

Skills & Requirements

• H.S. Diploma or GED Required
• RPHT-TX - Reg Pharmacy Technician by the TX State Board of Pharmacy required  
• CPHT - Cert-Pharm. TECH Certification by the Pharmacy Technician Certification Board preferred  
• 2 years pharmacy technician experience preferred  
• 1 year pharmacy (PBM) adjudication experience preferred 

About Texas Children’s

Since 1954, Texas Children’s has been leading the charge in patient care, education and research to accelerate health care for children and women around the world. When you love what you do, it truly shows in the smiles of our patient families, employees and our numerous accolades such as being consistently ranked as the best children’s hospital in Texas, and among the top in the nation by U.S. News & World Report as well as recognition from Houston Business Journal as one of this city’s Best Places to Work for ten consecutive years. 

Texas Children’s comprehensive health care network includes our primary hospital in the Texas Medical Center with expertise in over 40 pediatric subspecialties; the Jan and Dan Duncan Neurological Research Institute (NRI); the Feigin Tower for pediatric research; Texas Children’s Pavilion for Women, a comprehensive obstetrics/gynecology facility focusing on high-risk births; Texas Children’s Hospital West Campus, a community hospital in suburban West Houston; Texas Children’s Hospital The Woodlands, the first hospital devoted to children’s care for communities north of Houston; and Texas Children’s Hospital North Austin, the new state-of-the-art facility providing world-class pediatric and maternal care to Austin and Central Texas families. We have also created Texas Children’s Health Plan, the nation’s first HMO focused on children; Texas Children’s Pediatrics, the largest pediatric primary care network in the country; Texas Children’s Urgent Care clinics that specialize in after-hours care tailored specifically for children; and a global health program that is channeling care to children and women all over the world. Texas Children’s Hospital is affiliated with Baylor College of Medicine, one of the largest, most diverse and successful pediatric programs in the nation. 

 To join our community of 15,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities.

 Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.