Medical Claims Manager

Robert Half • Nashville, TN • 1d ago

Description

Our mission driven client is looking for a Medical Claims Manager to join their team in Nashville, Tennessee. In this contract role, you will handle auditing and reviewing pharmacy claims to ensure compliance and accuracy. This position requires onsite presence and offers an exciting opportunity to apply your expertise in medical claims and insurance processes.

Responsibilities:

Conduct comprehensive audits of pharmacy claims provided by the Pharmacy Benefits Company to verify accuracy and compliance.

Review and analyze data sets of paid pharmacy claims, ensuring alignment with insurance carrier criteria.

Examine claims by sorting them based on dates, amounts, drugs, and insurance carriers to identify discrepancies or outliers.

Create and maintain detailed audit requirements using Excel spreadsheets, including the application of conditional formatting.

Collaborate with stakeholders to ensure proper deductibles are applied and accurate payments are processed.

Monitor high-volume claims, particularly during peak months, to ensure proper allocation and adherence to state-approved insurance plans.

Utilize critical thinking to identify and resolve irregularities within claims data.

Follow established guidelines and specifications to ensure consistency and accuracy in auditing processes.

Provide detailed reports on findings and recommend corrective actions where necessary.

Maintain organized records of all audits and claims for future reference and compliance checks.

Requirements

Proven experience in medical claims management or auditing.

Strong proficiency in Excel, including advanced functions such as conditional formatting.

Familiarity with insurance carrier processes and guidelines.

Attention to detail and ability to identify discrepancies in large data sets.

Excellent analytical and problem-solving skills.

Knowledge of pharmacy claims and related processes is helpful.

Ability to work onsite in Nashville, Tennessee.

Effective communication skills to liaise with team members and stakeholders.

Robert Half is the world's first and largest specialized talent solutions firm that connects highly qualified job seekers to opportunities at great companies. We offer contract, temporary and permanent placement solutions for finance and accounting, technology, marketing and creative, legal, and administrative and customer support roles.

Robert Half works to put you in the best position to succeed. We provide access to top jobs, competitive compensation and benefits, and free online training. Stay on top of every opportunity - whenever you choose - even on the go. Download the Robert Half app (https://www.roberthalf.com/us/en/mobile-app) and get 1-tap apply, notifications of AI-matched jobs, and much more.

All applicants applying for U.S. job openings must be legally authorized to work in the United States. Benefits are available to contract/temporary professionals, including medical, vision, dental, and life and disability insurance. Hired contract/temporary professionals are also eligible to enroll in our company 401(k) plan. Visit roberthalf.gobenefits.net for more information.

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