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. Analysts are accountable for submitting payments within deadlines and in compliance with CMS guidelines and Rebate contract terms.
This position also helps in resolving dispute resolution, weekly pay run activities, SOX audits, system upgrade/implementation and ad hoc analysis.
Job Responsibilities:
- 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 recommendations 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 the 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 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 recommendations 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 the manager for key findings and changes to state programs. 5%
Skills:
- Pharmaceutical experience is a must! The candidate has to quickly join in and start. Medicaid rebate experience in pharm environment. 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 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.
- Medicaid rebate experience in pharm environment.
- 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
- 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.
Education/Experience:
- Bachelor’s degree/ High school Diploma 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 volumes 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.
