Pre-Payment Claims Analyst
Gainwell Technologies
full-time
Posted on:
Location Type: Remote
Location: Remote • Ohio • 🇺🇸 United States
Visit company websiteSalary
💰 $47,000 - $67,200 per year
Job Level
JuniorMid-Level
About the role
- Researching and analyzing pre-payment pharmacy claim data, systems, and documents to develop concepts or identify claim overpayments
- Reviewing interface errors, maintaining the fee schedule, and supporting provider and department setup
- Developing training materials and preparing operational reports
- Analyzing pharmacy claims for completeness, accuracy, and proper payment prior to release
- Investigating and analyzing data and processes to identify trends and responding to ODM requests
- Assisting with the design and implementation of new processes and systems to support business needs
- Investigating Ohio Medicaid pharmacy claim overpayments and denials through pre-payment audits
Requirements
- National Pharmacy Technician Certification (CPhT) required (PTCB or NHA)
- Bachelor’s or Master’s degree in Business, Audit, Insurance, Healthcare, or a related field preferred, or equivalent work experience
- Minimum of 2 years of experience in claim analytics, claims processing, benefit configuration, or QA/auditing within healthcare
- 1–2 years of managed care, insurance, or pharmacy benefit management experience preferred
- Medicaid experience strongly preferred
- Demonstrated proficiency with software tools used to generate provider-specific reports
- Proficient in Microsoft Office, with advanced skills in Excel and Access for spreadsheet and database management
- Working knowledge of pharmacy claims payment configuration processes and systems
- Strong understanding of claims processing workflows
- Solid problem-solving ability with experience performing root-cause analysis
- Skilled in developing training materials and documentation
Benefits
- Comprehensive health benefits
- 401(k) employer match
- Generous, flexible vacation policy
- Educational assistance
- Leadership and technical development academies
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
claim analyticsclaims processingbenefit configurationQA auditingpharmacy claims payment configurationroot-cause analysisdata analysisreport generationtraining material developmentoperational reporting
Soft skills
problem-solvingattention to detailanalytical thinkingcommunicationorganizational skills
Certifications
National Pharmacy Technician Certification (CPhT)