Remote Pharmacy Claims Audit Lead

Gainwell Technologies; Missouri; Remote; USD 47,000 - 68,000; Full time

Benefits offered by this job

401(k) match

Health benefits

Educational assistance

Generous vacation policy

Job summary

Gainwell Technologies, a leading provider of healthcare technology solutions, seeks a Pharmacy Claims Audit Supervisor to manage claims program administration remotely across the US. The role prioritizes proper claims practices, regulatory compliance, and efficient processing for client populations.

The supervisor will oversee billing and administrative activities, mentor staff, and coordinate with third parties on denials and settlements while advancing risk controls and process improvements.

Qualifications

• Bachelor's degree or equivalent combination of education and experience.
• Six or more years of claims experience.
• Two or more years of leadership experience.
• Experience with computer-based analysis tools.
• Experience with insurance terminology.

Responsibilities

• Supervises claims program administration to ensure proper claims practices and procedures.
• Supervises billing, claims and associated administrative activities to ensure compliance with laws, regulations, policies, agreements and contractual arrangements.
• Assists in implementing procedures to adjust claims when original demographic, sponsor or charge information is in error; monitors and controls resubmission of denials, rejections and appeals.
• Intercedes with third parties in unusual situations involving payment or adjustment of charges on accounts; consults with departments concerning services which affect collection of charges.
• Assists examiners in investigating claims and assists and/or performs settlement negotiations. Supervises claim settlement processing.
• Assumes supervisory responsibility for electronic and paper claims submissions; oversees analysis, correction and resubmission of registration and eligibility of edits and errors.
• Recommends and/or initiates the selection and hiring of employees. Trains and evaluates employees to enhance their performance, development, and work product. Addresses performance issues and makes recommendations for personnel actions. Makes recommendations for salary increases, transfers and terminations to manager.
• Researches coding and reimbursement requirements for compliance with local, state and federal regulations.

Skills

Leadership

Claims experience

Regulatory knowledge

Analytical skills

Insurance terminology

Communication skills

Education

Bachelor's degree

Business administration/insurance preferred

Job description

Gainwell Technologies, a leading provider of healthcare technology solutions, seeks a Pharmacy Claims Audit Supervisor to manage claims program administration remotely across the US. The role prioritizes proper claims practices, regulatory compliance, and efficient processing for client populations.

The supervisor will oversee billing and administrative activities, mentor staff, and coordinate with third parties on denials and settlements while advancing risk controls and process improvements.