Renew Health’s mission is to fundamentally transform how medications are managed in the health care system. To do so, we are building a modern and flexible tech stack that will anchor a highly differentiated approach to pharmacy benefits. This technology will power an innovative set of clinical services and exceptional member experience, which together can improve access, increase adherence, and ensure that members maximize the clinical benefit they receive from medications.
We believe that our approach will reduce population costs, decrease medication errors, and dramatically improve clinical outcomes. It will also allow us to align our business model with the interests of health plans and patients--passing through savings to clients and members, and generating revenue through clinical services that improve care and lower costs.
Our initial team includes co-founders of Oscar, Devoted, and Lyra Health, as well as alumni of top companies, including Microsoft, Amazon, McKinsey, Snapchat, DaVita, Google, Cityblock Health, AppNexus, The New York Times, and GoodRx. To date, we have raised $13M in funding, led by Venrock.
About the role:
Renew Health is seeking a Claims Analyst to oversee the accurate and timely adjudication of claims transactions and streamline adjudication processes. This position will help with the administration of our plans’ benefits, networks and formularies. The Claims Analyst has a broad understanding of the different systems, processes and configurations that impact claims adjudication and must stay current on claim processing procedures and CMS guidelines.
- Review claims systematically, by targeted issue(s) and by random sampling
- Identify and research claims processing anomalies, report trends in claims rejections, determine the root cause of claims that are not processed correctly and help with solutions to address the underlying issues
- Partner across teams as needed when researching claims
- Develop analyses to identify and quantify the member impact by issue
- Monitor the timeliness of claims processing, flag and investigate any delays
- Facilitate and review the processes that support retroactive claims adjudication changes for member updates related to, but not limited to, LICS eligibility changes, FIR transactions, etc; ensure that claims reprocessing adheres to CMS requirements
- Verify the accuracy of reimbursements, member payments and accumulators
- Maintain files and documentation of all claims analyses
- Assist with PDE submission, reporting, monitoring and reconciliation
- Administer and QA annual benefits setups
- Administer and QA benefits setups for testing purposes, assist with the reconciliation of test claims, research specific claims as needed
- Report potential areas of non-compliance to Compliance Officer and help with resolution
- Work closely with Compliance Officer, CMS, Plan Sponsors, and auditors to provide detailed responses to mock audits, audit inquiries and other compliance requests
- Develop, implement and maintain an audit tracking and documentation system
Qualifications and Skills:
- Extensive work experience in claims operations environment in Medicare Part D business
- Deep knowledge of and experience in all aspects of pharmacy claims adjudication including procedures, processes, governing rules and compliance
- Strong understanding of configurations for Medicare Part D for areas such as benefits, networks and formularies
- Intermediate proficiency in MS Excel; SQL experience is a plus
- 2+ years of data analysis and complex ad hoc analysis experience
- Team player with a collaborative working style
- Careful attention to detail with the ability to multitask on different projects and timelines
- National Certified Pharmacy Technician (CPhT) license is preferred
- Desire to join an early-stage company with a bold vision for making a fundamental transformation in a historically-fraught area of the healthcare industry
- Ability to thrive in an entrepreneurial, fast-paced environment with limited resources
- Sense of humor and humility
- Willingness to relocate to Los Angeles (if living elsewhere)