Pharmacy Audit & Claims Integrity Specialist

HCM Nexus; Cebu City; On-site; PHP 201,000 - 357,000; Full time

Job summary

Nexus Recruitment Group is seeking a Pharmacy Audit Support Representative to join our team. The role focuses on reviewing and analyzing pharmacy claims to ensure regulatory and internal standards are met, communicating with providers, and supporting audit processes to maintain accuracy in claims systems.

The candidate should have at least 1 year of pharmacy and administrative/customer service experience, with strong MS Office skills and knowledge of pharmacy practices.

Qualifications

• At least 1 year of experience in a pharmacy setting and 1 year of administrative or customer service experience.
• Working knowledge of Microsoft Office (Word, Excel) and familiarity with database systems.
• Pharmacy Technician license or certification is an advantage but not required.
• Strong knowledge of pharmacy practices, prescription interpretation, and standard medication dosages.
• Excellent communication skills (verbal and written) with the ability to manage sensitive provider interactions.
• Highly organized, detail-oriented, and capable of working independently.

Responsibilities

• Review pharmacy claims against company policies and regulatory guidelines to identify errors or potential fraud.
• Communicate with pharmacy providers to verify billing details and request claim adjustments when necessary.
• Document audit support findings, prepare reports, and maintain accurate records of communications.
• Review prescriptions, dispensing activities, and supporting documents for billing accuracy.
• Escalate compliance concerns, including cases of suspected fraud, waste, or abuse.
• Prepare correspondence and coordinate with internal teams to support the provider audit process.
• Participate in special projects, reporting, and problem resolution activities.

Skills

Pharmacy knowledge

MS Office

Database familiarity

Communication skills

Organized / detail-oriented

Independence

Adaptability

Education

Pharmacy Technician license (advantage)

Tools

Microsoft Word

Microsoft Excel

Database systems

Job description

About the job Pharmacy Audit Support Representative

About the Role
We are seeking a Pharmacy Audit Support Representative to join our team. This role is responsible for reviewing and analyzing pharmacy claims to ensure compliance with regulations and company standards. The position involves working closely with pharmacy providers, verifying claims data, identifying discrepancies, and supporting audit processes to maintain the accuracy and integrity of our claims systems.

Key Responsibilities

Review pharmacy claims against company policies and regulatory guidelines to identify errors or potential fraud.

Communicate with pharmacy providers to verify billing details and request claim adjustments when necessary.

Document audit support findings, prepare reports, and maintain accurate records of communications.

Review prescriptions, dispensing activities, and supporting documents for billing accuracy.

Escalate compliance concerns, including cases of suspected fraud, waste, or abuse.

Prepare correspondence and coordinate with internal teams to support the provider audit process.

Participate in special projects, reporting, and problem resolution activities.

Qualifications

At least 1 year of experience in a pharmacy setting and 1 year of administrative or customer service experience.

Working knowledge of Microsoft Office (Word, Excel) and familiarity with database systems.

Pharmacy Technician license or certification is an advantage but not required.

Strong knowledge of pharmacy practices, prescription interpretation, and standard medication dosages.

Excellent communication skills (verbal and written) with the ability to manage sensitive provider interactions.

Highly organized, detail-oriented, and capable of working independently.

What We're Looking For

Adaptability and problem-solving skills in fast-paced environments.

Strong professionalism, customer focus, and commitment to accuracy.

Ability to handle multiple priorities and meet deadlines.

Standard office hours: Monday to Friday, 8:00am 5:00pm (overtime or weekend work may occasionally be required).

This role may involve limited travel depending on business needs.