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 to ensure accurate payment determination.
• Assist with special projects and provide training and guidance to team members.
• Investigate and resolve claims issues, including overpayments and denials, using root cause analysis.
• Create and maintain files according to organizational guidelines, ensuring accuracy and compliance.
• Remain up-to-date on federal and state payment policies, as well as company policies and procedures.
• Work collaboratively with various stakeholders, including pharmacies, members, and insurance representatives.

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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.