Sr. Pharmacy Claims Analyst
Contract W2
Contract Independent
3 Months
No Travel Required
Remote
Depends on Experience
Kainos Innovative Solutions Inc
Fitment
Dice Job Match Score™
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Job Details
Skills
- Prior Authorization (PA) Expertise
- Claims adjudication
- Formulary expertise
- Drug approval lifecycle
- Data analysis
- Pricing knowledge
- Compliance (Medicare/Medicaid)
Summary
Position: Senior Pharmacy Claims Analyst
Location: Remote
Duration: 3 Months Contract-to-Hire Potential
About the Role:
Key Responsibilities:
Prior Authorization & Drug Approval:
Formulary & Claims Analysis:
Compliance & Collaboration:
Required Qualifications:
Preferred Qualifications:
Location: Remote
Duration: 3 Months Contract-to-Hire Potential
About the Role:
- We are seeking a Senior Pharmacy Claims Analyst with deep, hands-on expertise in prior authorization (PA) and the end-to-end drug approval lifecycle. In this role you will own the analysis and adjudication review of pharmacy claims from the point of submission by covered entities through to final approval or denial, including the management of clinically appropriate drug substitutions and step-therapy pathways.
- This is a senior individual-contributor position for someone who knows formulary data inside and out, understands how coverage decisions are made, and can move confidently between the clinical, operational, and regulatory dimensions of pharmacy benefits. You will be a go-to subject-matter expert, helping resolve complex cases, surface trends, and improve the accuracy and speed of our approval process.
Key Responsibilities:
Prior Authorization & Drug Approval:
- Review, analyze, and adjudicate prior authorization requests against clinical criteria, plan design, and formulary rules, driving each case to a timely and well-documented approval or denial.
- Manage the full drug approval workflow—from initial submission by covered entities (including 340B and other covered entities) through clinical review, determination, and member/provider notification.
- Evaluate and apply step therapy, quantity limits, age/diagnosis edits, and medical-necessity criteria consistently and defensibly.
- Identify and recommend clinically appropriate drug substitutions (therapeutic interchange, generic/biosimilar substitution) in line with formulary tiers and coverage policy.
- Serve as an escalation point for complex, high-cost, or appealed cases, providing clear rationale that withstands clinical and regulatory scrutiny.
Formulary & Claims Analysis:
- Maintain expert-level command of formulary data—tiers, NDC-level coverage, exclusions, preferred/non-preferred status, and rebate-relevant placements — and apply it accurately to claims and PA decisions.
- Analyze pharmacy claims data to detect adjudication errors, pricing discrepancies, utilization outliers, and potential fraud, waste, or abuse.
- Reconcile claims against plan design and reimbursement terms, investigating rejections and resolving root causes.
- Build and deliver reports and dashboards on PA volumes, turnaround times, approval/denial rates, and drug utilization trends.
Compliance & Collaboration:
- Ensure all determinations comply with applicable federal and state regulations and accreditation standards (e.g., CMS, Medicare Part D, Medicaid, commercial plan requirements).
- Document decisions thoroughly to support audits, appeals, and regulatory review.
- Partner with pharmacists, clinical staff, network pharmacies, and benefit teams to clarify cases and refine criteria.
- Recommend process and policy improvements that increase accuracy, reduce turnaround time, and improve the provider and member experience.
Required Qualifications:
- 5+ years of experience in pharmacy claims, pharmacy benefits, or managed care, with a clear track record in prior authorization and drug approval.
- Expert knowledge of the end-to-end PA and drug approval process—from covered-entity submission through approval, denial, appeals, and substitution.
- Strong, demonstrated mastery of formulary data and structure (tiers, NDC codes, edits, exclusions, preferred status).
- Solid understanding of claims adjudication, pharmacy pricing concepts (e.g., AWP, MAC), rebates, and reimbursement.
- Working knowledge of regulatory and compliance requirements across Medicare, Medicaid, and commercial lines of business.
- Proficiency with data analysis tools—advanced Excel required; SQL and/or BI tools (Tableau, Power BI) strongly preferred.
- Excellent documentation, judgment, and communication skills, with the ability to justify determinations clearly.
- Certified Pharmacy Technician (CPhT), PharmD, RN, or equivalent clinical/managed-care background highly desirable.
Preferred Qualifications:
- Experience with PBM or health-plan adjudication platforms and prior authorization systems.
- Familiarity with 340B and covered-entity program requirements.
- Experience supporting appeals, grievances, and audit readiness.
- Background contributing to formulary management or clinical criteria development.
Employers have access to artificial intelligence language tools (“AI”) that help generate and enhance job descriptions and AI may have been used to create this description. The position description has been reviewed for accuracy and Dice believes it to correctly reflect the job opportunity.
- Dice Id: 91138973
- Position Id: 8981361
- Posted 3 hours ago
Company Info
About Kainos Innovative Solutions Inc
Kainos was established in early 2019 and is headquartered in Falls Church, Virginia. Though a humble beginning, we bring proven expertise in-depth knowledge gained through working in key roles in multinational companies serving global customers in the IT industry over the last few decades.
With our expertise, we understand the complexity of today’s and next generation technologies. This enables us to deliver Innovative solutions for global challenges that are scalable, optimal and secure for Government Agencies and Commercial Clients delivered on-time customized to fit the budget and meeting the business needs. Our areas of expertise include providing Digital Services, Application, Data & Infrastructure Services, Cyber Security Services, Professional Services, and Customer Support Services.
Our focus is to offer customized solutions and service with cost effective solutions. We faithfully strive to be a customer-centric organization.
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