• Pharmacy Claims Analyst

    Job Location US-MI-Detroit
    Job ID
    Business Line
  • Overview

    Who we are:

    MeridianRx is a full-service Pharmacy Benefit Manager (PBM) committed to driving down costs and elevating quality. Our clients experience better quality outcomes, thanks to effective clinical support, patient education, and specialty pharmacy programs.

    We work with a diverse range of clients, from members to healthcare providers to plan administrators. MeridianRx services clients across the country and our network continues to grow.

    Our employees work hard, play hard, and give back. MeridianRx employees enjoy: Happy hours, special events, company sports teams, potlucks, Bagel Fridays, and volunteer opportunities.


    A Day in the Life of an Pharmacy Claims Analyst:

    Coordinates and conducts the activities of the Pharmacy Claims Auditing program.  Ensures that Medicaid, Commercial, Medicare, and Specialty claims are processed accurately by the MERLIN claims engine as well as ensure manually priced claims are correct and any staff placed overrides are audited for quality and accuracy.


    • Review a designated percentage of paid and rejected claims for Medicaid
    • Review a designated percentage of Commercial claims for HIX and MeridianRx clients – pursuant to the established benefit of the client – through oversight and monitoring of both paid and rejected pharmacy claims
    • Ensure accurate claim adjudication with respect to cost-sharing, tiering, and accumulators
    • Have knowledge of commonly-used concepts, practices and procedures within pharmacy operations
    • Perform assigned tasks according to established guidelines
    • Ensure compliance with all company, state and federal rules and regulations
    • Work closely with clinical, call center, and other operational/technical areas to provide support for daily PBM claims activities with regard to payment integrity
    • Develop and enhance processes that ensure payment integrity
    • Conduct override audits of call center and clinical staff to ensure that staff meet or exceed accuracy standards
    • Review designated percentage of price Specialty claims
    • Work closely with Sr. Claims Analysts and leadership for support and guidance
    • Work closely with the Training and Development department to ensure consistency in training across the Claims department
    • Meet or exceed claim production goals as set by management while meeting or exceeding the department quality goals
    • Assist with special projects related to department process improvements, fraud, waste and abuse identification or other issues


    What you can bring to MeridianRx:

    • Bachelor’s degree or Fellow designation from the Academy for Healthcare
    • Management (AHM) is required
    • Knowledge of HIPAA
    • Knowledge of customer service expectations related to quality and service
    • Knowledge of all aspects of claims processing
    • Working knowledge of Microsoft Office tools (Word, Excel, and Outlook)
    • Strong knowledge of MERLIN is preferred
    • Strong analytical, organizational and communication skills
    • Good problem solving skills
    • Good interpersonal skills necessary to interact with all levels of personnel


    What MeridianRx can offer you:

    • Healthcare benefits that include a variety of plans, which are effective on the first day of employment for our new full-time team members. 
    • Opportunity to work with the industry’s leading technologies and participate in unique projects, demonstrations, conferences, and exclusive learning opportunities.
    • 401k matching that is above the national average. 
    • Full-time MeridianRx employees are eligible for tuition reimbursement towards Bachelor’s or graduate degrees.
    • A bright and engaging company culture; the Meridian family of companies has been recognized as one of Metro Detroit’s Best and Brightest Companies to Work For 5 years in a row. 


    Equal Opportunity Employer




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