Pharmacy Claims Audit Supervisor

Job not on LinkedIn

🔥 0 minutes ago

🏰 Missouri – Remote

🏰 Missouri – Remote

💵 $47.3k - $67.6k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

💊 Pharmacist

🦅 H1B Visa Sponsor

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Gainwell Technologies

WebsiteLinkedInAll Job Openings

10,000+ employees

💼 Consulting

📦 Logistics

⚕️ Healthcare Insurance

💰 Grant on 2023-06

Consulting • Logistics • Healthcare Insurance

Gainwell Technologies is the nation’s leading provider of digital and cloud-enabled solutions across the human services and public health ecosystem. With a mission-driven approach, Gainwell serves clients in all 50 U. S. states, focusing on improving health outcomes and delivering intuitive, human-centered experiences. Their comprehensive suite of solutions includes Medicaid Enterprise modernization, data analytics, provider services, and pharmacy solutions, all designed to advance the future of healthcare and enhance community well-being.

📋 Description

• Lead and develop a team responsible for drug claims auditing and adjudication activities • Oversee claim audit workflows for accuracy, timeliness, and compliance with PBM and Medicaid guidelines • Monitor productivity, quality, and turnaround-time metrics • Implement process improvements to identify discrepancies • Manage escalations and resolve complex claims issues involving members, providers, and pharmacies • Partner with internal teams on system updates, audits, and ongoing claims operations • Work with the state to present audit findings, develop new capabilities, and manage appeal processes • Provide leadership within a high-volume audit processing environment • Collaborate with pharmacy, clinical, client, and IT teams

🎯 Requirements

• Must hold an active Pharmacy Technician certification (CPhT), such as PTCB • 5+ years of PBM, pharmacy operations, drug claims processing, and audit operations experience • 2+ years of leadership or supervisory experience • Strong knowledge of identifying drug claim anomalies and pharmacy audit operations • Strong knowledge of pharmacy claims adjudication and Medicaid programs • Experience with client communications and leading discussions with clients • Experience with operational reporting, KPIs, and process improvement

🏖️ Benefits

• Flexible hours and work flexibility • Work-life balance • Medical, dental, and vision benefits • 401(k) options • 401(k) employer match • Flexible vacation policy • Educational assistance • Leadership and technical development academies • Career development and continuous learning opportunities