About the company:
They have more than 4,500 employees working to transform how people experience health care. Recognized as a Top 100 Healthiest Workplaces and among the World's Most Ethical Companies, we are rooted in a legacy that puts people first, always.
They are dedicated to making the healthcare experience simpler, better, and more affordable for people and their families, including the 3.3 million people they serve through their regional health plans.
They are deeply rooted in a 100-year legacy of transforming the industry and how people experience health care. And they're committed to delivering a seamless, personalized healthcare experience for the next 100 years. They have taken their legacy business and pivoted to meet the needs of today's healthcare consumers.
Clinical Review Pharmacy Analyst:
Our client is seeking a Clinical Review Pharmacy Analyst to support post-service claim audits and ensure the accuracy and compliance of pharmaceutical billing. This role leverages strong knowledge of medications, healthcare documentation, and reimbursement policies to evaluate claims and identify discrepancies. The ideal candidate is detail-oriented, analytical, and able to manage competing priorities while maintaining high standards of accuracy and regulatory compliance.
++This role is fully remote. Applicants who reside in Oregon, Washington, Utah, or Idaho are preferred.++
Clinical Review Pharmacy Analyst Responsibilities:
- Conduct detailed post-service audits of pharmacy-related claims to ensure billed charges align with medical records, drug administration documentation, and reimbursement policies.
- Analyze pharmaceutical billing and treatment documentation to identify discrepancies, incorrect charges, or use of medications outside approved treatment guidelines.
- Request and review additional documentation when necessary to validate claims and support audit findings.
- Maintain compliance with regulatory, accreditation, and organizational standards while ensuring work meets established accuracy, quality, and turnaround expectations.
- Manage assigned audit workload independently, prioritizing tasks to meet productivity goals and departmental timelines.
- Maintain organized access to policies, procedures, and reference materials needed to perform claim and billing reviews effectively.
- Contribute to operational efficiency by supporting cross-functional tasks, participating in departmental initiatives, and assisting with special projects as assigned.
Clinical Review Pharmacy Analyst Qualifications:
- Licensed Practical Nurse (LPN) or Licensed Pharmacy Technician certification required.
- 5+ years of combined experience in healthcare claims review, pharmacy billing analysis, or related healthcare auditing functions.
- Recent hands-on experience working in an inpatient IV room compounding sterile pharmaceuticals is required.
- Minimum of 2 years of clinical or healthcare facility experience (hospital or residential treatment setting preferred).
- Strong knowledge of pharmaceuticals and drug administration practices, including the ability to identify inappropriate billing, off-label use, or investigational treatments.
- Experience reviewing healthcare claims and billing documentation, with familiarity in medical records and reimbursement policies.
- Demonstrated ability to work independently, meet productivity and quality standards, and manage multiple priorities in a fast-paced environment.
- Strong analytical, problem-solving, and communication skills.
- Proficiency with Microsoft Office and general computer applications.
- Experience using AI tools or technology to support analysis and decision-making is highly preferred.
- Payment review, medical coding, or audit experience is a plus.
Status: 6-Month Contract Pay: $23-$25/hr Location: 100% Remote