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Pharmacy Recovery & Compliance Coordinator in Orange at Prospect Medical Systems

Date Posted: 3/13/2019

Job Snapshot

Job Description

Pharmacy Recovery & Compliance Coordinator    

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

Review high cost pharmacy claims and resolve issues in collaboration with the Claims Department.

Job Responsibilities/Duties

  • Conduct internal claims audits for drugs and pharmacy related supplies (e.g., diabetic supplies) to identify duplicate claims and erroneously processed claims for recovery.
  • Troubleshoot by contacting providers, health plans, hospitals, and internal departments to determine the root cause of the issues.
  • Collaborate with the Claims Department to ensure the receipt of payment from providers.  Create reports to track the recovery progress of inappropriate pharmacy claims.
  • Create tools/job aids and train pharmacy staff and other pertinent departments on any risk areas involving HCPCS codes (e.g., CPT, J/S/C/Q codes), claims processes, and system configuration. 
  • Work in collaboration with the Director of Pharmacy and IT/IDX Operations team to review and update system edits that affect pharmacy claims as needed.
  • Process high cost pharmacy claims in a timely manner with accuracy to facilitate correct processing of claims.
  • Identify risk mitigation areas to be targeted based on the claims review process to implement and create necessary operational workflows or changes.


Minimum Education: High School Diploma.

Minimum Experience: Medical coding/billing experience for injectable and infusion claims.

Req. Certification/Licensure: None.

Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals you will receive:

  • Company 401K
  • Medical, dental, vision insurance
  • Paid time-off
  • Life insurance

How to Apply

To apply for this role, or search our other openings, please visit and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

EEOC is the Law:

Keywords: Compliance, Medical Billing, Coding, Claims, Pharmacy, Referral