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, 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.

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