Job title: Clinical Review Pharmacy Analyst
Location: Remote Work– Must live in the client footprint: Oregon, Washington, Idaho or Utah
Contract Length: 6+ months; chance of extending/converting 
Pay rate: 25-27/HR
Note: Looking for IV admixture skills as this is needed for this role. 

Seeking a Clinical Review Pharmacy Analyst responsible for utilizing knowledge of drugs and pharmaceuticals to conduct post-service audits and ensure the accuracy of billed charges.

This role analyzes billing and medical documentation to determine whether charges align with medical records, pharmaceutical treatments, and reimbursement policies. The position requires strong analytical ability, familiarity with healthcare documentation, and the ability to maintain productivity and quality standards within a fast-paced environment.

This is a temporary contract position working remotely within the United States. Candidates must be able to work Pacific Time Zone hours.

Key Responsibilities

• Conduct post-service audits using knowledge of drugs and pharmaceuticals to ensure billing accuracy.
• Prioritize work, set goals, and coordinate activities to ensure timely completion of record reviews and audits according to team workflow.
• Analyze billings to determine if charges are consistent with medical records, drug administration, and reimbursement policies.
• Identify incorrectly billed medications, IV fluids, and pharmaceutical treatments.
• Evaluate documentation to determine investigational or off-label drug use when applicable.
• Identify when additional information is required and request supporting documentation when necessary.
• Follow strict guidelines to ensure work meets corporate standards for accuracy, timeliness, quality, and regulatory compliance.
• Maintain organized access to reference materials, policies, and procedures required to perform audits.
• Complete assigned work while meeting productivity and quality standards.
• Support departmental efficiency through flexibility and cross-training on additional functions.
• Perform special projects as requested by the supervisor.

Minimum Requirements

• Demonstrated competency in claim review and experience using billing and claims forms.
• In-depth knowledge of drugs and pharmaceuticals to identify incorrectly billed medications and IV fluids.
• Ability to identify drug use for non-FDA approved treatments, investigational use, or off-label administration.
• Familiarity with healthcare documentation.
• Strong oral and written communication skills.
• Demonstrated initiative and strong problem-solving skills.
• Ability to consistently meet productivity and quality standards with minimal supervision.
• Ability to work in a fast-paced, multi-tasking environment with changing priorities.
• General computer skills including Microsoft Office, Outlook, and Internet research.
• Experience with AI tools and technologies to enhance productivity and decision-making in professional settings is highly desired.

Experience Requirements

Candidates are typically expected to have:

• A license or certification as a Pharmacy Technician or Licensed Practical Nurse, and
• 2 years of experience in a hospital or residential treatment facility, and
• 3 years of health insurance claims experience or analytical experience,
  or an equivalent combination of education and experience.

Payment review or coding experience is considered a plus.

Required Licenses or Certifications

• Licensed Practical Nurse (LPN)
  or
• Licensed Pharmacy Technician

Work Environment

• Work is primarily performed in an office environment while working remotely.
• Candidates must be willing to work Pacific Time Zone hours and may occasionally be required to work outside normal business hours.
• Local or out-of-state travel may be required.
• Company-provided equipment will be used.

 

Medical Review Support Analyst

Location: Remote
Duration: 6 Months
Pay Rate: $20/hr

Job Summary:

The Medical Review Support Analyst supports clinical audit and claims review processes by triaging claims, requesting and managing medical records, and ensuring accurate documentation within claims systems. This role works closely with claims teams and provider networks to gather required records, track claim review status, and ensure compliance with healthcare regulations and organizational standards.

Key Responsibilities

• Perform initial triage of claims selected for review to determine if they meet specific clinical audit criteria.

• Request and obtain medical records from healthcare providers based on review requirements.

• Prepare and send medical record request letters and follow up on outstanding documentation.

• Receive, review, and process medical records received via fax, mail, email, and secure upload systems.

• Research claim history and review pre-authorization determinations when necessary.

• Enter claim processing instructions and documentation into Facets or other claims systems.

• Maintain accurate case notes and required fields in departmental databases.

• Communicate claim review status and documentation updates to claims staff and network management teams.

• Send detailed provider notifications when records are missing or additional documentation is required.

• Maintain production, quality, and compliance standards while adhering to healthcare regulatory requirements.

Required Qualifications

• High School Diploma or GED.

• 3+ years of experience in a healthcare environment, such as:

  • Medical office

  • Claims processing

  • Medical billing

  • Healthcare customer service
    (or equivalent education and experience combination)

• Strong written and verbal communication skills.

• Experience working with medical records, billing, or healthcare documentation.

• Ability to research issues, analyze information, and resolve problems independently.

• Strong organizational skills with the ability to prioritize tasks and meet deadlines.

• Basic understanding of medical terminology.

Preferred Qualifications

• Experience using Facets claims system.

• Knowledge of medical coding, anatomy, or healthcare claims processes.

• Familiarity with BlueCard, ITS processes, FEP Direct, or Salesforce.

• Analytical and basic math skills for claims review analysis.