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 PBM Claims Analyst is responsible for research, collection, validation, reconciliation and data analysis in utilizations and financial Rx claims data within the TX VDP Medicaid (FFS) domain. Also, for the completion of all reprocessing tasks and claims adjustments in a timely manner. Must have the ability to work with multiple departments within the organization, in an effort to coordinate analytics to enhance operational efficiencies.
Your role in our mission
• Review and audit pharmacy claims and calculate reimbursement for financial recoupment based on contract terms to determine accuracy, quality checking of payment through use of various reports and supporting documentation, track the status of multiple pharmacy key metrics in accordance with guidelines, Key Performance Indicators (KPIs) and Service Level Agreements (SLAs) & determine root cause to better mitigate issues.
• Responsible for testing validation, monitoring, and analysis of the claims module with continued efforts relating to process improvement and system fixes to increase claims reprocessing efficiency, compliance and to reduce overall errors.
• Resolves reoccurring provider or member claims issues by identifying trends and recommending solutions to upper leadership.
• Resolves escalated claims issues by researching and resolving claims issues via root-cause analysis (RCA) and providing timely responses; Liaison to external recovery business partners, such as SIU units, and fraud, waste, and abuse.
• Responsible for the ongoing maintenance and data integrity of the claims and Encounter data; establishes and validates plan parameters, utilization management and benefit setup.
What we're looking for
• 2 or more years of experience in a claims processing, analytical, benefit configuration or QA/auditing role in PBM required
• 1 or more years of managed care, insurance, or pharmacy benefit management experience
• Medicaid and/or similar PBM Operations experience
• Demonstrated proficiency with software applications capable of provider-specific reports; SQL knowledge and SSRS environment knowledge a plus
• Detail-oriented problem-solving skills, able to quickly spot trends and discrepancies, with financial acumen and strong analytical thinking skills required
What you should expect in this role
• Remote-United States/Puerto Rico/ US Virgin Islands, work-from-home position
• Limited travel (
