PBM Claims Adjudication Specialist
New
A
AffirmedRxPharmacy Benefit Management
RemoteFull-TimeMiddle
Salary not disclosed
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Job Details
- Experience
- 7+ years
- Required Skills
- Data Analysis
Requirements
- Bachelor’s degree in a related field, or equivalent experience.
- 7+ years of direct PBM experience building and maintaining client eligibility and accumulator files.
- Deep, hands-on experience with PBM claims adjudication and how claims interact with eligibility and accumulator data.
- Strong knowledge of NCPDP standards, claims processing rules, and benefit design.
- Experience with SFTP setup, configuration, and management for secure file transmission.
- Excellent troubleshooting and problem-solving skills.
- High attention to detail.
- Willingness to travel (10%-20%).
- Experience with the RxSense platform (plus).
Responsibilities
- Design, build, and configure new client eligibility files based on requirements and benefit plan designs.
- Translate client eligibility rules and benefit structures into accurate file specifications.
- Design, build, and maintain accumulator files reflecting member deductibles and out-of-pocket data.
- Develop automations and scripts to streamline file build, testing, and validation.
- Configure and manage SFTP connections for secure client file transmissions.
- Ensure eligibility and accumulator data accuracy across all clients.
- Serve as the team's expert on adjudication logic and NCPDP standards.
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