Claims Analyst - Remote US

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

The Pre-Payment Claims Analyst is responsible for analyzing pre-payment pharmacy claims data, systems, and documents to identify potential claim overpayments and ensure claims are paid accurately. This includes reviewing interface errors, maintaining fee schedules, creating operational reports, and supporting the development of training materials. The individual will assist with developing and implementing new processes or modifying existing processes to meet business needs. Additionally, the Analyst will investigate Ohio Medicaid pharmacy claim overpayments and denials to determine the root cause and identify trends through various pre-payment audits.

Your role in our mission

• Assist with the development and periodic review of educational materials, workflows, and documentation for assigned business units.
• Audit pharmacy claims and attached documentation to verify reimbursement accuracy and ensure proper claims processing based on contract terms.
• Analyze data trends and suggest process improvements to enhance the revenue cycle and payer contract compliance.
• Review and approve/deny claims, ensuring fees are accurate and proper authorizations are submitted.
• Assist in identifying, validating, and recovering claim overpayments through research and analysis.
• Communicate with internal departments, external stakeholders, and Ohio Medicaid to resolve claims issues and inquiries.

What we're looking for

• Bachelor's or Master's degree in Business, Audit, Insurance, Healthcare, or related field preferred (or equivalent work experience).
• At least 2 years of experience in claims analysis, claims processing, benefit configuration, or auditing in healthcare.
• Experience in managed care, insurance, or pharmacy benefit management preferred.
• Proficiency with pharmacy claims payment configuration systems, as well as MS Office, particularly Excel and Access.
• Strong problem-solving capabilities and ability to perform root cause analysis to identify areas for process improvement.
• Ability to recognize data discrepancies and irregularities in claim submissions.

What you should expect in this role

• Analyze pharmacy claims pre-payment data and systems …