Supervisor, Claims Services

🔥 1 minute ago

🏰 Missouri – Remote

🏰 Missouri – Remote

💵 $47.3k - $67.6k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Gainwell Technologies

WebsiteLinkedInAll Job Openings

10,000+ employees

⚕️ Healthcare Insurance

💰 Grant on 2023-06

Healthcare Insurance • Human Services • Healthcare

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

• Supervises claims audit operations within Pharmacy Benefit Management (PBM) services • Ensures accurate adjudication of pharmacy claims while maintaining compliance with Medicaid requirements and operational performance standards • Oversee claim audit workflows to ensure accuracy, timeliness, and compliance with PBM and Medicaid guidelines • Monitor performance metrics (productivity, quality, turnaround times) and implement process improvements to identify discrepancies • Manage escalations and resolve complex claims issues involving members, providers, and pharmacies • Partner with internal teams to support system updates, audits, and ongoing claims operations • Work with state to present audit findings, develop new capabilities and manage appeal processes

🎯 Requirements

• 5+ years of experience in pharmacy operations, drug claims processing, audit, or related healthcare environments • 2+ years of leadership experience managing teams and driving performance • Strong expertise in pharmacy claims adjudication, Medicaid programs, audit processes, and identifying claims anomalies • Nationally Certified Pharmacy Technician (CPhT) required; CFE or AHFI certification preferred • Experience with client communications, reporting (KPIs), and driving operational improvements

🏖️ Benefits

• generous, flexible vacation policy • 401(k) employer match • comprehensive health benefits • educational assistance • variety of leadership and technical development academies