Claims Analyst I (Remote)

Description

Temp to Perm: Contingent only. *6 to 8 month Contingent assignment.*

Shift: Remote OR Hybrid.

Monday – Friday 8:00am – 5:00pm.

Hybrid workers have Tuesday and Wednesday onsite and Monday, Thursday and Friday from home.

Remote workers are fully remote.

Core Essential Skill Sets

• Medicaid rebate experience must be in pharmaceutical environment.
• Prior Medicaid Claim processing experience with a Pharmaceutical company only, 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.
  
  

Position Summary

The Medicaid Claims Analyst is responsible for Medicaid Drug Rebate process which includes validating, verifying, disputing when necessary, and remitting payment for assigned state Medicaid agencies, SPAPs and Supplemental Rebates. Analyst is accountable for submitting payments within deadlines and in compliance with CMS guidelines and Client rebate contract terms.

This position also provides assistance in resolving dispute resolution, weekly pay run activities, SOX audits, system upgrade/implementation and ad hoc analysis.

Essential Duties & Responsibilities Percentage Of Time

• 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 recommendation 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 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 Client 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 recommendation 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 manager for key findings and changes to state programs. 5%
  
  

Position Requirements

Education Required: Bachelor’s degree 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 experience

Experience 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 volume 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.

Travel Requirements: Minimal

Core competencies

Analysis

• Uses good analytical and data interpretation skills to analyze and resolve complex problems
• Analyzes processes and systems to improve efficiency and effectiveness through standardization, simplification and automation.
  
  

Developing Self and Others

• Coaches and counsels associates to improve performance toward individual and department goals
• Continuously expands technical and personal skills and business knowledge
  
  

Interpersonal Ability

• Develops and fosters strong relationships with internal and external clients
• Builds reputation for being credible, trustworthy, and fair
• Displays high level of integrity by doing what is right for the company
• Demonstrates administrative value to shared service customers
  
  

Planning and Organization

• Committed to meeting deadlines
• Demonstrates sense of urgency by effectively prioritizing workload according to organizational needs
• Demonstrates the ability to manage multiple priorities
  
  

Technical Skills

• Possesses solid accounting skills particularly around accuracy and internal controls
• Demonstrates advanced data management and Excel skills
• Understands fundamental mechanics of rebate systems