Supervisor, Claims Services - Remote US

Gainwell Technologies LLC•Any city, OH

6d•$47,300 - $67,600•Remote

About The Position

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. Your role in our mission 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 What we're looking for 5+ years of experience in pharmacy operations, drug claims processing, audit, or related healthcare environments 2+ years of leadership experience managing teams and driving performance Strong expertise in pharmacy claims adjudication, Medicaid programs, audit processes, and identifying claims anomalies Nationally Certified Pharmacy Technician (CPhT) required; CFE or AHFI certification preferred Experience with client communications, reporting (KPIs), and driving operational improvements What you should expect in this role Leadership within a high-volume audit processing environment Collaboration with pharmacy, clinical, clients and IT teams Focus on accuracy, compliance, and operational efficiency

Requirements

5+ years of experience in pharmacy operations, drug claims processing, audit, or related healthcare environments
2+ years of leadership experience managing teams and driving performance
Strong expertise in pharmacy claims adjudication, Medicaid programs, audit processes, and identifying claims anomalies
Nationally Certified Pharmacy Technician (CPhT) required
Experience with client communications, reporting (KPIs), and driving operational improvements

Nice To Haves

CFE or AHFI certification preferred

Responsibilities

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