Pharmacy Lead Claims Analyst - Remote US

Category: Healthcare

About the Company:
Join Gainwell, a company that solves business challenges and enhances the way we work and grow. Gainwell carries its rewards, offering incredible opportunities for career growth in a company that values your contributions and puts a premium on work flexibility, learning, and career development. We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone.

Summary:
Reporting to the Claims Manager, the Lead Claims Analyst will be responsible for researching and analyzing paid and denied claims, POS system issues, and pricing discrepancies. The Lead Claims Analyst will work closely with the Claims Manager to research pharmacy claims processing issues and inquiries, including edit changes or new edit creation, respond to pharmacy inquiries, and develop an understanding of how the pharmacy claims processing system operates.

Your Role in Our Mission:

• Assist Claims Manager with the day-to-day operations of the Claims Team, including training and/or mentoring less experienced staff, PPAC inquiries, POS test case creation and validation, and post-implementation claims monitoring.
• 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.
• Provide training and guidance to team members by providing feedback to management on claims, provider issues, and updating client business rules.
• Acquire knowledge of the claim adjudication system, member and provider contracts, and client claim payment policies and procedures.
• Resolve claims issues by researching claim situations and providing timely responses.

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.
• Generous, flexible vacation policy.
• 401(k) employer match.
• Comprehensive health benefits.
• Educational assistance.
• Variety of leadership and technical development academies.

Pay Range:

• $58,800.00 - $84,000.00 per year (base pay may vary based on geographic region, internal equity, job-related knowledge, skills, and experience).

Location: Remote (US)
Work Model: Remote
Languages: Not specified