Pharmacy Claims Audit Supervisor - Remote US

It takes great medical minds to create powerful solutions that solve some of healthcare's most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you've honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you'll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You'll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.

Summary

Your role in our mission

Essential Job Functions

• 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.

Basic Qualifications

• Bachelors degree or equivalent combination of education and experience
• Bachelors degree in business administration, insurance or related field preferred
• Six or more years of claims experience
• Two or more years of leadership experience
• Experience working with proper claims handling, policies and procedures
• Experience working with computer based analysis tools
• Experience working with insurance and/or medical terminology

Other Qualifications

• Organizational skills to balance and prioritize work
• Analytical and problem solving skills
• Communication skills
• Human relations skills to select, develop, mentor, discipline and reward employees
• Negotiation skills to interact with claimant
• Ability to understand and convey applicable laws, regulations and practices regarding the insurance industry
• Ability to work independently and lead group activities

Work Environment

• Office environment

What were looking for

What you should expect in this role

The pay range for this position is $47,300.00 - $67,600.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You'll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.

We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You'll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.

Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. Gainwell Technologies defines "wages" and "wage rates" to include "all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.