[Hiring] Pharmacy Claims Audit Supervisor @Gainwell Technologies LLC

Role Description

Supervises claims audit operations within Pharmacy Benefit Management (PBM) services. Ensures accurate adjudication of pharmacy claims while maintaining compliance with Medicaid requirements and operational performance standards. The Claims Audit Supervisor will have oversight of all FWA Audit Services including Concurrent Claims Review, Desk Audit and Field Audit.

• Lead and develop a team responsible for drug claims auditing and adjudication activities
• Oversee claim audit workflows to ensure accuracy, timeliness, and compliance with PBM and Medicaid guidelines
• Monitor performance metrics (productivity, quality, turnaround times) and implement process improvements to identify discrepancies
• Manage escalations and resolve complex claims issues involving members, providers, and pharmacies
• Partner with internal teams to support system updates, audits, and ongoing claims operations
• Work with state to present audit findings, develop new capabilities and manage appeal processes

Qualifications

• Must hold an active Pharmacy Technician certification (CPhT), such as PTCB
• 5+ years of PBM, pharmacy operations, drug claims processing and audit operations experience
• 2+ years of leadership or supervisory experience
• Strong knowledge of identifying drug claim anomalies and pharmacy audit operations
• Strong knowledge of pharmacy claims adjudication and Medicaid programs
• Experience with client communications and leading discussions with clients
• Experience with operational reporting, KPIs, and process improvement

Requirements

• This is a remote work from home position
• Leadership within a high-volume audit processing environment
• Collaboration with pharmacy, clinical, clients and IT teams
• Focus on accuracy, compliance, and operational efficiency

Benefits

• Access to Gainwell’s competitive benefits package for eligible employees, including medical, dental, vision, and 401(k) options in accordance with applicable eligibility guidelines
• Generous, flexible vacation policy
• 401(k) employer match
• Comprehensive health benefits
• Educational assistance
• Variety of leadership and technical development academies to help build your skills and capabilities