Pharmacy Pre/Post Payment Claims Analyst - Remote

Benefits

• 401(k)
• 401(k) matching
• Flexible schedule
• Health insurance
• Tuition reimbursement

It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.

Summary

Reporting to the Claims Manager, the Pre-Payment Claims Analyst and/or Post-Payment Claims Analyst will be responsible for researching and analyzing claims pre-payment and/or post-payment pharmacy data, systems, and documents to develop new concepts or apply existing concepts to identify claim overpayments and claims that paid incorrectly. This includes the review of interface errors, maintenance of the fee schedule, provider and department set-up, 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 ODM 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 Post-Payment Claims Analyst investigates Ohio Medicaid pharmacy claim over-payments and denials to determine root cause analysis identified through various pharmacy post-payment audits.

Your role in our mission

• 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.
• Creates, maintains, and closes files in accordance with policies and guidelines.
• Provide training and guidance to team members on market specific issues by providing feedback to management on claims, provider issues, and updating client business rules.
• Prepare and review recurring and monthly reporting metrics for external stakeholders and in response to specific requests.
• Respond to inquiries from Ohio State Medicaid and internal departments.

What we're looking for

• 2 years of experience in a claim analytical, claims processing, benefit configuration or QA/auditing role in healthcare required.
• 1-2 years of managed care, insurance, or pharmacy benefit management experience preferred.
• Medicaid experience preferred.
• Required understanding of and experience related to pharmacy claims payment configuration process/systems.
• Experience with health care reimbursement.

What you should expect in this role

• Video cameras must be used during all interviews, as well as during the initial week of orientation.
• This is a 100% remote position.
• In order to effectively work as a teleworker with Gainwell, employees Broadband Internet connections, should have a minimum speed of 24MBS download and 8 MBS upload. Greater speeds will of course provide better performance.
• To Test your internet download and upload speed:
• Go to Google
• Search for Internet Speed Test or click here.

The pay range for this position is $47,000.00 - $67,200.00 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 committed to a diverse, equitable, and inclusive workplace. We are proud to be 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), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. We celebrate diversity and are dedicated to creating an inclusive environment for all employees.