Medicaid Claims Analyst

SGS Consulting; New York (NY); Presencial; USD 70.000 - 110.000; Jornada completa

Descripción de la vacante

SGS Consulting seeks a Medicaid data specialist to process quarterly invoices, validate claim-level data, and upload to Model N/Medicaid systems. You will resolve discrepancies and document errors while ensuring rebate eligibility and data integrity.

The role requires independent analysis, attention to detail, and strong Excel and data manipulation skills, with experience in Medicaid processing within the pharmaceutical sector.

Formación

• Experience with Medicaid invoicing and rebate processing in a pharma/healthcare setting.
• Experience handling large data sets and writing/maintaining audit trails.
• Knowledge of CMS Medicaid rules and state-specific issues is a plus.

Responsabilidades

• Work with assigned states to obtain Medicaid Summary invoice and related data quarterly; upload into Medicaid systems and authorize transactions.
• Perform initial quality checks on summary data to ensure rebate eligibility and data consistency.
• Conduct Claim Level Detail validation and resolve disputes for historical utilization submissions.
• Notify states of results/findings and document errors for research and process improvements.
• Provide backup support to Medicaid team and help establish best practices within the work environment.

Conocimientos

Pharmaceutical experience

Medicaid rebate experience

Medicaid claim processing

Excel skills

Data manipulation

Attention to detail

Educación

Bachelor's degree

High school diploma

Herramientas

Model N

Revitas/Flex

Flex Validata

Descripción del empleo

Job Responsibilities

Work with assigned states to get Medicaid Summary invoice, summary data file and Claim Level Invoice each quarter and review to ensure completeness of information received. Upload data into Medicaid systems and authorize transactions. Document errors and perform research.Conduct initial quality check on summary data on all claim submissions to ensure rebate eligibility and data consistency – 20%Perform Claim Level Detail validation. Review suspect claim records and determines if record should be disputed for payment – 20%Resolve disputes and propose recommended amounts to be paid for historical outstanding utilization that is routinely submitted with Medicaid claims. Must have ability to work independently and make recommendations on state disputes, apply proper amounts to be paid &; ensure CMS codes are applied correctly; notify states of results/findings – 20%Complete Medicaid analyzes and documentation on assigned states/programs. Communicate to the manager for key findings and changes to state programs – 10%Provide backup for Medicaid team members in any necessary functions and work with team to establish best practices within Medicaid work environment – 5%Work with assigned states to get Medicaid Summary invoice, summary data file and Claim Level Invoice each quarter and review to ensure completeness of information received. Upload data into Model N / Medicaid systems and authorize transactions. Document errors and perform research – 5%Conduct initial quality check on summary data on all claim submissions to ensure rebate eligibility and data consistency – 5%Perform Claim Level Detail validation. Review suspect claim records and determines if record should be disputed for payment. 5%Resolve disputes and propose recommended amounts to be paid for historical outstanding utilization that is routinely submitted with Medicaid claims. Must have ability to work independently and make recommendations on state disputes, apply proper amounts to be paid &; ensure CMS codes are applied correctly; notify states of results/findings. 5%Complete Medicaid analyzes and documentation on assigned states/programs. Communicate to the manager for key findings and changes to state programs. 5%

Skills

Pharmaceutical experience is a must! The candidate has to quickly join in and start. Medicaid rebate experience in pharm environment. Prior Medicaid Claim processing experience with a Pharmaceutical and/or med Device company, state and/or state agency or as Medicaid consultant or equivalent work experience Minimum 2+ years pharmaceutical/product focused healthcare experience; Medicaid Claim processing function; manipulation of large datasets, negotiation/conflict resolution. System Implementation and report writing. Revitas/Flex Medicaid and advance Microsoft Excel skills. Strong ability to organize and manipulate large volume of data in various formats. Attention to detail and high degree of accuracy in data processing and reviews.Medicaid rebate experience in pharm environment.Prior Medicaid Claim processing experience with a Pharmaceutical and/or med Device company, state and/or state agency or as Medicaid consultant or equivalent work experienceMinimum 2+ years pharmaceutical/product focused healthcare experience; Medicaid Claim processing function; manipulation of large datasets, negotiation/conflict resolution. System Implementation and report writing.Revitas/Flex Medicaid and advance Microsoft Excel skills.Strong ability to organize and manipulate large volume of data in various formats. Attention to detail and high degree of accuracy in data processing and reviews.

Education/Experience

Bachelor’s degree/ High school Diploma or equivalent combination of experience, training and/or direct work-related experience.Experience Required: Prior Medicaid Claim processing experience with a Pharmaceutical and/or med Device company, state and/or state agency or as Medicaid consultant or equivalent work experienceExperience Preferred: Minimum 2+ years pharmaceutical/product focused healthcare experience; Medicaid Claim processing function; manipulation of large datasets, negotiation/conflict resolution. System Implementation and report writing.Specialized or Technical Knowledge, License, Certifications needed: Knowledge of the Model N or Revitas/Flex Medicaid and/or Flex Validata system (or other comparable system) and advance Microsoft Excel skills.Familiar with CMS Medicaid rules and state specific issues. Up to date knowledge on Medicaid Validation rules and issues with 340B covered entities.Strong ability to organize and manipulate large volumes of data in various formats. Attention to detail and high degree of accuracy in data processing and reviews.Company/Industry Related Knowledge: Medicaid, Government Pricing and Rebate Pharmaceutical industry experience/knowledge prefer.