Pharmacy High-Cost Drug Analyst
Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. Deployed by over 85 health plans, including many of the top 20, and representing more than 270 million lives, Machinify brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise. We’re constantly reimagining what’s possible in our industry, creating disruptively simple, powerfully clear ways to maximize financial outcomes and drive down healthcare costs.
About the Opportunity
The High-Cost Drug Analyst works on behalf of health plans to investigate, identify, and recover overpayments of specialty drug claims paid through medical and pharmacy systems. The Analyst will review information related to how a drug was administered and billed (e.g., billed units, intended dose, sourcing, etc.), use the online client system to better understand the related medical encounter, and confirm probable overpayments with the healthcare provider. The analyst will then work with the provider to recover the overpayment on behalf of the client.
What you’ll do
- Investigates to confirm that drug claims are billed and paid correctly
- Analyzes claims data and healthcare records, applying specialized knowledge of prescription drugs, provider practices, and health insurance benefit structure
- Communicates with healthcare providers and insurers to gather required information
- Utilizes all available resources to maximize identification and recovery of overpayments
- Answers phone calls in a timely fashion and resolves issues
- Creates, maintains, and closes files in accordance with policies and guidelines
- Assists with submitting overpaid claims in client vendor management systems, as needed
What experience you bring (Role Requirements)
- Bachelor’s Degree or equivalent combination of experience in health insurance or related fields, which would provide the necessary knowledge, skills and abilities to successfully perform the work
- Medical claim billing and/or coding experience is extremely valuable, but not required
- Experience in the pharmaceutical field is helpful, but not required.
- Professional oral and written communication skills, including excellent phone communication skills
- Comfortable working in computer applications
- Very strong critical thinking, attention to detail, and organizational skills
- Ability to work well independently or in a team environment
- Proficiency with Microsoft Word and Excel
What Success Looks Like…
After 3 months
- You will have a strong understanding of the role.
- You begin building relationships and collaborating with peers.
- You develop effective time and priorities management.
- You receive initial feedback about your performance and are using it to improve.
- You’ve gained confidence in your abilities and are starting to feel more comfortable in your role.
After 1 year
- You have mastered the tasks and responsibilities of the position, executing them with confidence and efficiency.
- You have established a strong network of internal relationships and are recognized as a key collaborator.
- You’ve been entrusted with greater responsibility indicating the company’s confidence in your abilities.
- You see opportunities for career progression and personal development.
Pay range: This is an exempt position with an annual base salary of $47,000 with significant monthly bonus.
What’s in it for you
- PTO, Paid Holidays, and Volunteer Days
- Eligibility for health, vision and dental coverage, 401(k) plan participation with company match, and flexible spending accounts
- Tuition Reimbursement
- Eligibility for company-paid benefits including life insurance, short-term disability, and parental leave.
- Remote and hybrid work options
What values we’ll share with you
- Ask why
- Think big
- Be humble
- Optimize for customer impact
- Deliver results
