Medicaid Claims Analyst

Role Summary

The Medicaid Claims Analyst is responsible for Medicaid Drug Rebate processes, including validating, verifying, disputing when necessary, and remitting payment for assigned state Medicaid agencies, SPAPs, and Supplemental Rebates. The analyst submits payments within deadlines and in compliance with CMS guidelines and contract terms, and provides assistance with dispute resolution, weekly pay runs, SOX audits, system upgrades/implementations, and ad hoc analysis. This is a hybrid role reporting to Parsippany, NJ or North Wales, PA, depending on location.

Responsibilities

• Work with assigned states to obtain Medicaid Summary invoices, summary data files, and Claim Level Invoices each quarter; review for completeness; upload data into Medicaid systems and authorize transactions; document errors and perform research.
• Conduct initial quality checks on summary data to ensure rebate eligibility and data consistency.
• Perform Claim Level Detail validation; review suspect claim records and determine if a record should be disputed for payment.
• Resolve disputes and propose recommended payment amounts for historical utilization; work independently, apply proper amounts, ensure CMS codes are applied correctly, and notify states of results/findings.
• Complete Medicaid analyses and documentation on assigned states/programs; communicate key findings and changes to state programs to the manager.
• Provide backup for Medicaid team members and collaborate to establish best practices within the Medicaid work environment.
• Upload data into Model N/Medicaid systems (or equivalent) and document errors; repeat data validation steps as needed.

Qualifications

• Education: High School Diploma required; Bachelor‚Äôs degree preferred. Equivalent experience considered.
• Experience: Prior Medicaid claim processing experience with pharmaceutical/medical device companies, state agencies, or as a Medicaid consultant, or equivalent.
• Experience Preferred: 2+ years in pharmaceutical/product-focused healthcare; Medicaid claim processing; handling large datasets; negotiation/conflict resolution; system implementation and report writing.

Skills

• Knowledge of Model N or Revitas/Flex Medicaid and/or Flex Validata systems or similar; advanced Microsoft Excel skills.
• Familiarity with CMS Medicaid rules and state-specific issues; up-to-date knowledge of Medicaid validation rules and issues with 340B entities.
• Strong data organization and manipulation abilities; high attention to detail and accuracy in data processing and reviews.

Education

• High School Diploma required. Bachelor‚Äôs degree preferred. Any equivalent combination of experience, training, and/or direct work-related experience will be considered.

Additional Requirements

• Knowledge of Medicaid, Government Pricing, and rebate processes; preferred experience in the Medicaid/pharmaceutical industry.