Pharmacy Lead Claims Review Analyst - Remote US

Great companies need great teams to propel their operations. Join the group that solves business challenges and enhances the way we work and grow. Working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values your contributions and puts a premium on work flexibility, learning, and career development.

Summary

Reporting to the Claims Manager, this Lead Claims Review Analyst will be responsible for understanding processes and assisting both the prepayment and postpayment claims review teams. This includes researching and analyzing pre- and post-payment pharmacy data, systems, algorithms, and documents to develop new concepts or apply existing concepts to identify claim overpayments and claims that paid incorrectly. This includes correspondence with pharmacies, development of training materials, operational reporting, and creation/update of workflows. Pharmacy claims are analyzed for completeness, accuracy, and payment determination, after claims payable. The individual investigates and analyzes data, systems, and processes for the purposes of identifying issues/trends and responding to client requests. This position also assists with the design and implementation of new processes/systems or changes in processes/systems to support our business needs. The Lead Claims Review Analyst investigates Ohio Medicaid pharmacy claim over-payments through various pharmacy pre- and post-payment audits.

Your role in our mission

• Assist Claims manager with the day-to-day operations of the Concurrent Claims Review and Desk Claims Review programs
• Assist with the development and periodic review of educational documents and workflows to ensure that materials are up-to-date and meet the objectives of the assigned business units.
• Assist with development and management of Concurrent Claims Review program
• Assist with management of Desk Claims Review program
• Lead both prepayment and postpayment claims teams

What we're looking for

• Bachelor’s degree in business, audit, healthcare, or related field preferred or equivalent work experience.
• 2 years of experience in a claim analytical, claims processing, benefit configuration or QA/auditing role in healthcare required.
• Required understanding of and experience related to pharmacy claims payment configuration process/systems.
• Required pharmacy claims processing knowledge.
• Nationally Certified Pharmacy Technician

What you should expect in this role

This is a 100% remote position.

#LI-REMOTE #LI-JT1

The pay range for this position is $58,800.00 - $84,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.

We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.

Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.