Professional Claims Analyst - Remote US

Summary

Reporting to the Claims Manager, the Claims Analyst will be responsible for researching and analyzing paid and denied claims, POS system issues, and pricing discrepancies. The Claims Analyst will work closely with the Claims Manager to research pharmacy claims processing issues and inquiries including edit changes or new edit creation, respond to pharmacy inquiries, and develop an understanding of how the pharmacy claims processing system operates. In this role, you will evaluate claims trends, assess financial reporting practices, and identify opportunities to improve claims systems and operational processes. This position requires strong analytical expertise, sound judgment, and a thorough understanding of claims procedures and industry standards.

Your role in our mission

• Assist the Claims Manager with day-to-day Claims Team operations, including training or mentoring less experienced staff, POS test case creation and validation, ad hoc smoke testing, weekly system deployments, post-implementation claims monitoring, and annual testing activities performed during and outside standard working hours.
• Assist with the development and periodic review of educational documents and workflows to ensure materials remain current and aligned with the objectives of assigned business units.
• Provide training and guidance to team members, offer feedback to management on claims and provider issues, and support updates to client business rules while acquiring knowledge of the claim adjudication system, member and provider contracts, and client claim payment policies and procedures.
• Resolve claims issues by researching claim situations and providing timely responses, while communicating with pharmacies, members, and insurance representatives to gather necessary information.
• Generate required client reporting, support audits by providing documentation and responding to inquiries, and assist with special projects and related team goals as determined by the Claims Manager.

What we're looking for

• Bachelor’s degree in insurance, business administration, or a related field, or an equivalent combination of education and experience, with a minimum of three years of claims experience.
• Experience working with industry-standard claims processing systems and investigative tools, along with knowledge of claims processing procedures, documentation standards, administrative guidelines, and relevant legislative requirements.
• Ability to work under tight deadlines, manage multiple responsibilities, and work independently with minimal supervision in a fast-paced environment.
• Strong analytical, organizational, and problem-solving skills, with financial acumen, strong attention to detail, excellent time management, and the ability to quickly identify trends and discrepancies.
• Required understanding of and experience related to pharmacy claims payment configuration processes and systems, required pharmacy claims processing knowledge, Medicaid experience preferred, strong written and verbal communication skills, general computer proficiency including Microsoft Office and Excel, and Nationally Certified Pharmacy Technician certification.

What you should expect in this role

• Remote work environment with collaboration across claims, compliance, and leadership teams throughout the U.S.
• High level of responsibility in reviewing sensitive financial and personal data while maintaining strict confidentiality.
• Opportunities to contribute to continuous improvement initiatives that enhance claims accuracy, reporting, and operational efficiency.
• Reliable high-speed internet connection required, with minimum download speed of 25 Mbps and upload speed of 10 Mbps.
• Access to Gainwell’s comprehensive benefits package in accordance with eligibility guidelines, including medical, dental, vision, 401(k), and other employee programs.