Exl Service

  • Pharmacy Claims Overpayment Analyst, Decision Analytics Services

    Job Location US-NJ-Jersey City
    Regular Full-Time
    Job Code
  • Overview

    Pharmacy Claims Overpayment Analyst


    EXL (NASDAQ: EXLS) is a leading business process solutions company that looks deeper to drive business impact through integrated services and industry knowledge. EXL provides operations management, decision analytics and technology platforms to organizations in insurance, healthcare, banking and financial services, utilities, travel, transportation, and logistics.


    We work as a strategic partner to help our clients streamline business operations, improve corporate finance, manage compliance, create new channels for growth and better adapt to change. EXL Analytics employs cost-effective, state-of-the-art analytics to help companies obtain meaningful data to optimize customer targeting, new customer acquisition, cross-selling opportunities, risk management, and overall profitability. Headquartered in New York and in business since 1999, EXL has more than 23,000 professionals in locations throughout the U.S., Europe and Asia.


    EXL is the leader in area of identifying Medical and Pharmacy claims overpayment. EXL offers claims overpayment services to its key clients. Our domain SMEs work closely with the analytics teams to identify fraud patterns, potential abuses, and overpayment scenarios with millions of dollars as recoverable amount.


    Please visit www.exlservice.com for more information about EXL Analytics.


    Role Overview:

    • As a pharmacy claims overpayment analyst, you will be responsible for creating potential pharmacy overpayment/fraud/waste scenarios that will be tested by the data analytics team
    • Additionally, you will review the pharmacy claims that have been identified as potential overpayment claims by the analytics team. Once confirmed the claims will be submitted for rectification and potential recovery from the pharmacy
    • As an analyst you will be required to interface closely with the business analysts and data scientists in the Pharmacy Fraud Analytics division in EXL
    • As a Pharmacy claims expert you will considered as the pharmacy claims format domain SME who is comfortable working on claims as well data from many other sources to identify the key fields that help in building the overpayment scenarios
    • Maintain documentation around the scenarios and present it to the senior management


    • Comply with HIPAA and other regulations regarding confidentiality
    • Conduct accurate and detailed pharmacy claims audits in accordance with State and Federal Regulations
    • Identify and determine if pharmacy overpayments have occurred, documenting them with standard discrepancy codes


    • Analyze data output for the pharmacy claims identified by analytics team in Excel/SAS platform to accurately review, merge and interpret data from multiple data sources
    • Identify patterns, document the findings and share with the team to ensure accuracy and build comprehensive audit
    • Develop pharmacy overpayment scenarios and document it along with the fields to be used by the analytics team to test the hypothesis
    • Work with BI reports specialists to build data visuals that accurately depict findings from audit that are shared with leadership
    • Manage multiple pharmacy overpayment scenarios and track the progress on each assignment with the analytics team



    • Master’s or Bachelor's degree in electronics/electrical engineering, computer science, IT or related quantitative analytics field from top-tier universities with strong record of achievement.
    • Expert level knowledge of Pharmacy claims data and other related data sources including the pharmacy calculations and conversions
    • Pharmacy Audit experience with exposure to pharmacy fraud/overpayment scenarios
    • Minimum of 5 years of collective experience as a Pharmacy auditor for PBM, Pharmacy data analyst, or Pharmacy claims analyst
    • Excellent Excel skills, word processing and database knowledge
    • Excellent verbal and communication skills.
    • Ability to work at a fast pace while meeting company accuracy guidelines.
    • Knowledge of PBM Pharmacy claims processing system and processes
    • Experience of working with the analytics division and data warehousing teams
    • Work Location: EXL: Jersey City Office / Remote

    What we offer:

    • EXL Analytics offers an exciting, fast paced and innovative environment, which brings together a group of sharp and entrepreneurial professionals who are eager to influence business decisions. From your very first day, you get an opportunity to work closely with highly experienced, world class analytics consultants.
    • You can expect to learn many aspects of businesses that our clients engage in. You will also learn effective teamwork and time-management skills - key aspects for personal and professional growth
    • We provide guidance/ coaching to every employee through our mentoring program wherein every junior level employee is assigned a senior level professional as advisors.
    • Sky is the limit for our team members. The unique experiences gathered at EXL Analytics sets the stage for further growth and development in our company and beyond.



    EEO Statement



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