Data Analyst-Rx Claims & Pharmacy Domain

Jersey, NJ - USA

Monthly Salary: Not Disclosed

Posted on: 30+ days ago

Vacancies: 1 Vacancy

Job Summary

Role: Data Analyst

C2H

Location: Remote. The candidate may be expected to travel to NJ office 1-2 times in a month.

Must have experience on Rx claims and health insurance payer or PBM environment

Rx Claims & Pharmacy Domain

Analyse end-to-end Rx claims adjudication workflows including eligibility benefit design formulary pricing accumulators edits prior authorization and reversals
Interpret and validate pharmacy benefit requirements such as copays coinsurance deductibles OOP max step therapy quantity limits and formulary tiers
Support PBM integrations and data exchanges (e.g. eligibility files claims feeds rebates encounter data)
Perform root-cause analysis on claims payment issues rejects and member/provider escalations
Ensure claims logic aligns with CMS state Medicaid and commercial regulatory requirements

Data Analysis & Reporting

Query and analyze large Rx claims datasets using SQL and analytical tools to identify trends anomalies and financial impacts
Develop and maintain operational financial and compliance reports related to pharmacy utilization spend and claims accuracy
Support audits reconciliations and compliance reporting (e.g. CMS encounters PDEs state reporting)
Validate data accuracy across upstream and downstream systems

Systems & Business Analysis

Gather and document business requirements and translate them into functional specifications data mappings and system rules
Partner with IT and vendors to support system enhancements benefit changes releases and production issue resolution
Participate in UAT planning and execution including test case creation test data validation and defect triage
Support modernization initiatives including claims platform upgrades PBM transitions and data integrations

Cross-Functional Collaboration

Act as a liaison between Pharmacy Operations IT Finance Compliance and vendors
Communicate complex pharmacy and claims concepts clearly to technical and non-technical stakeholders

Required Qualifications

5 years of experience as a Data Analyst Systems Analyst or Business Analyst in a health insurance payer or PBM environment
Strong hands-on experience with Rx claims data and pharmacy benefit management
Advanced proficiency in SQL and experience working with large healthcare datasets
Solid understanding of pharmacy benefit design claims adjudication logic and payer operations
Experience supporting production issues audits and regulatory reporting
Excellent communication skills with the ability to work across technical and business teams

Preferred Qualifications

Experience with Rx claims platforms (e.g. Facets Rx QNXT RxClaim MedImpact Caremark OptumRx)

Familiarity with CMS Part D Medicaid pharmacy programs and encounter/PDE reporting

Regards

Manoj

Derex Technologies INC

Contact : Ext 206

Additional Information :

All your information will be kept confidential according to EEO guidelines.

Remote Work :

Yes

Employment Type :

Full-time

Role: Data Analyst C2HLocation: Remote. The candidate may be expected to travel to NJ office 1-2 times in a month. Must have experience on Rx claims and health insurance payer or PBM environment Rx Claims & Pharmacy DomainAnalyse end-to-end Rx claims adjudication workflows including eligibility bene...