Medicaid Claims Analyst

SGS_JOB_1385

Pharmacy
 New Jersey
Microsoft Excel
Pharmaceutical
Data processing

Contract - 06 Months

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.

Related Jobs

Pharmacist

Pharmacy
 California
$60-70/hr.
06+ Months Extendable

Location (mandatory): San Diego, CA 92103 This position is responsible for dispensing prescriptions and coordinating clinical services for specialty drugs serviced at the branch location. This position is responsible for interacting with the health care professionals in the provision and coordination of customer care. Must also translate prescriptions, perform compounds and dispense prescribed pharmaceuticals. Must be comfortable communicating by telephone or mail, with patients and physicians for patient care. Will also be responsible for resolving orders via the EA (External Adjudication) queue.

Pharmacist
RPH
Registered Pharmacist

Nurse Practitioner

Pharmacy
 South Carolina
06+ Months Extendable

Location (mandatory): Onsite in Lexington, SC 29072 Nurse Practitioners will work in collaboration with a dedicated clinical care team to provide evidenced-based care to a panel of patients. The clinical care team will work with the provider daily to drive better outcomes for entire panel of patients. This will include accurate assessment, diagnosis, treatment, management of health problems, health counseling, and disposition planning.

NP
Nurse Practitioner
FNP
Family Nurse Practitioner

Pharmacy Technician

Pharmacy
 Massachusetts
06+ Months Extendable

Location (mandatory): Onsite in Boston, MA 02115 Manages pharmacy workstations and tasks, supporting the team's ability to fill patient prescriptions, ensuring all medication needs and regulatory compliance standards are met for patients. National Certification PTCB or ExCPT

Pharmacy Technician
CPHT
Pharmacy
Prior Authorization
prescription
Medication
inventory
mixing
counting out
labeling

Nurse Practitioner

Pharmacy
 South Carolina
06+ Months Extendable

Location (mandatory): Onsite in Irmo, SC 29063 Nurse Practitioners will work in collaboration with a dedicated clinical care team to provide evidenced-based care to a panel of patients. The clinical care team will work with the provider daily to drive better outcomes for entire panel of patients. This will include accurate assessment, diagnosis, treatment, management of health problems, health counseling, and disposition planning.

NP
Nurse Practitioner
FNP
Family Nurse Practitioner

Pharmacy Technician

Pharmacy
 Ohio
03+ Months Extendable

Location (mandatory): Onsite in Cincinnati, OH 45246 Manages pharmacy workstations and tasks, supporting the team's ability to fill patient prescriptions, ensuring all medication needs and regulatory compliance standards are met for patients.

Pharmacy Technician
CPHT
Pharmacy
Prior Authorization
prescription
Medication
inventory
mixing
counting out
labeling

Executive Assistant, Marketing; Pharmacy and Healthcare Delivery

Pharmacy
 Rhode Island
06+ Months Extendable

Location (mandatory): Hybrid in Woonsocket, RI 02917 Provides various office and location support activities. Identifies, enhances, and follows specific processes and procedures to maximize the efficiencies of the business to which the support is being provided; ensures the correct functioning of facilities, office, and/or business support services.

Executive Assistant
Concur
Travel arrangement
Calander Management
Office Admin
HR Admin
Office Inventory

Sr. Analyst, 340B Contract Operations

Pharmacy
Remote
06+ Months Extendable

Location (mandatory): Remote in EST Timezone This is a contract-focused role titled 'Senior Analyst,' but it is not an analytical role in the traditional sense. The primary responsibilities center around contract operations and negotiations, particularly within the 340B program. The Sr. Analyst, 340B Contract Operations is responsible for 340B Program contract facilitation. The role includes extensive collaboration with internal teams including Legal, Sales, Implementations, Account Management, etc. Duties include drafting and negotiating new and existing business contracts utilizing a contract management software, coordinating with various subject matter experts, and moderating Legal calls to see contracts through to completion. The Sr. Analyst, 340B Contract Operations will interact with several different areas to successfully issue agreements, resolve client comments within contracts, and seek successful execution with team as appropriate This role handles contract operations negotiations with clients and is not an analytical role

340B program
Contract Negotiation
Contract Generation
Salesforce
CRM

Analyst II - DSCSA Product Flow

Pharmacy
Remote
06+ Months Extendable

Location (mandatory): Remote in EST Timezone This role will focus on monitoring, troubleshooting, and resolving serialization and traceability exceptions, managing serialization and exception handling under the Drug Supply Chain Security Act (DSCSA). Assist in training Health teams (Retail pharmacies and distribution centers, PBM Mail, PBM Specialty, etc.) on serialization compliance, exception management, and best practices

Supply Chain
PBM
Pharmacy Benefit management
Retail
Pharmacy
SQL
Tableau or BI tools
Financial Model
Serialization

HEDIS Reviewer III

Pharmacy
Remote
06+ Months Extendable

Location (mandatory): Remote for Michigan or Indiana State candidates HEDIS Medical Record Review (MRR) Abstractor III "Participates in the collection and review of medical records to abstract clinical information for HEDIS quality reporting. Training will be provided prior to the start of the assignment. This position interprets relevant clinical criteria through review of medical records, annotates via Adobe PDF and populates a data collection tool to support compliance with HEDIS and CMS performance measures. Ensures accurate and complete documentation of required information to meet risk management, regulatory, and accreditation requirements. The candidate must be proficient with databases and with conducting 100% of work activities on the computer.

HEDIS
DATA Entry
Medical Record Review
HEDIS Abstractor
logo

At SGS Consulting, we go beyond resume-job matches, creating meaningful connections and pathways for individuals to thrive in defining careers.


2025. All right reserved.
logologologologo