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It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.
Summary
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
Must hold an active Pharmacy Technician certificatioin (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
What you should expect in this role
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
Access to Gainwell’s competitive benefits package for eligible employees, including medical, dental, vision, and 401(k) options in accordance with applicable eligibility guidelines .
The pay range for this position is $47,300.00 - $67,600.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.
We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.
Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. Gainwell Technologies defines “wages” and “wage rates” to include “all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.
