Pre-Payment Claims Analyst

Summary

Reporting to the Claims Manager, the Pre-Payment Claims Analyst will be responsible for researching and analyzing pre-payment pharmacy claim data, systems, and documents to develop new concepts or apply existing concepts to identify claim overpayments and incorrectly paid claims. Responsibilities include reviewing interface errors, maintaining the fee schedule, supporting provider and department setup, developing training materials, preparing operational reports, and creating or updating workflows. Pharmacy claims are analyzed for completeness, accuracy, and proper payment determination prior to being released for payment. The individual also investigates and analyzes data, systems, and processes to identify issues and trends, as well as respond to ODM requests. This position assists with the design and implementation of new or updated processes and systems to support business needs. The Pre-Payment Claims Analyst also investigates Ohio Medicaid pharmacy claim overpayments and denials to determine root cause through various pre-payment audits.

Responsibilities

• Assist with developing and updating educational materials, workflows, and documentation
• Maintain files and records in accordance with company policies
• Provide training and guidance on market-specific issues and client business rules
• Prepare monthly and ad-hoc reporting metrics for internal and external stakeholders
• Respond to inquiries from Ohio Medicaid and internal departments
• Analyze data to identify trends and recommend process improvements
• Gain working knowledge of claims adjudication systems, contracts, and payment policies
• Review and audit pharmacy claims for accuracy, reimbursement compliance, and root-cause identification
• Assist in identifying and recovering overpayments and processing corrections
• Approve or deny claims based on fee accuracy, documentation, and authorization requirements
• Identify recurring issues and recommend solutions to management
• Resolve claim-related member or provider concerns and escalate trends as needed
• Help reduce claims-related service calls by identifying preventable issues
• Monitor changes in payment policies and regulations and support implementation
• Communicate with pharmacies, ODM, members, and insurance representatives
• Draft and send correspondence as neede
• Support department goals and assist with special projects assigned by the Claims Manager 

Essential Skills & Abilities

• Ability to work under tight deadlines, manage multiple priorities, and operate independently with minimal supervision
• Strong verbal and written communication skills with the ability to effectively engage all levels of staff and leadership
• Consistent and professional presentation skills
• Demonstrated ability to work collaboratively and adapt to changing situations
• Approachable, professional, and responsive in all interactions
• Strong attention to detail with problem-solving skills to quickly identify trends, discrepancies, and root causes; financial acumen and analytical thinking required
• Excellent time management and prioritization skills
• Strong organizational skills in a fast-paced environment
• Proficiency with Microsoft Office (especially Excel), internet research, and email
• Consistently meets position expectations and performance objectives
• Working knowledge of the regulatory environment and coding affecting pharmacy reimbursement
• Experience with healthcare reimbursement models and policies 

What we're looking for

• 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
• Ability to identify data inconsistencies within claim submissions and recognize recurring patterns or irregularities 

What you should expect in this role

• Work Arrangement: Remote within the United States
• Position Type: Full-time job

Applications for this posting will be accepted until November 25, 2025.