Claims Representative role in training for workers' compensation at Sedgwick. Involves investigation and resolution of claims with ongoing professional development.
About the role
- Medicaid Claims Analyst responsible for validating and remitting payments for Medicaid Drug Rebate processes. Ensuring compliance with CMS guidelines and Teva rebate contract terms.
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.
- Perform Claim Level Detail validation.
- Review suspect claim records and determines if record should be disputed for payment.
- Resolve disputes and propose recommended amounts to be paid for historical outstanding utilization that is routinely submitted with Medicaid claims.
- Complete Medicaid analyzes and documentation on assigned states/programs. Communicate to manager for key findings and changes to state programs.
Requirements
- Education Required: High School Diploma required. Bachelor’s degree preferred.
- 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 of 2+ years pharmaceutical/product focused healthcare experience; Medicaid Claim processing function; manipulation of large datasets, negotiation/conflict resolution.
- 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.
Benefits
- Comprehensive Health Insurance: Medical, Dental, Vision, and Prescription coverage starting on the first day of employment, providing the employee enrolls.
- Retirement Savings: 401(k) with employer match, up to 6% and an annual 3.75% Defined Contribution to the 401k plan.
- Time Off: Paid Time Off including vacation, sick/safe time, caretaker time and holidays.
- Life and Disability Protection: Company paid Life and Disability insurance.
- The total compensation package for this position may also include other elements, including a sign-on bonus, restricted stock units, and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.
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