Data Analyst Pharmacy Claims(Only on W2)
Role: Data Analyst
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
ā¢ Analyse end-to-end Rx claims adjudication workflows, including eligibility, benefit design, formulary, pricing, accumulators, edits, prior authorization, and reversals
ā¢ Interpret and validate pharmacy benefit requirements such as copays, coinsurance, deductibles, OOP max, step therapy, quantity limits, and formulary tiers
ā¢ Support PBM integrations and data exchanges (e.g., eligibility files, claims feeds, rebates, encounter data)
ā¢ Perform root-cause analysis on claims payment issues, rejects, and member/provider escalations
ā¢ Ensure claims logic aligns with CMS, state Medicaid, and commercial regulatory requirements
Data Analysis & Reporting
ā¢ Query and analyze large Rx claims datasets using SQL and analytical tools to identify trends, anomalies, and financial impacts
ā¢ Develop and maintain operational, financial, and compliance reports related to pharmacy utilization, spend, and claims accuracy
ā¢ Support audits, reconciliations, and compliance reporting (e.g., CMS encounters, PDEs, state reporting)
ā¢ Validate data accuracy across upstream and downstream systems
Systems & Business Analysis
ā¢ Gather and document business requirements and translate them into functional specifications, data mappings, and system rules
ā¢ Partner with IT and vendors to support system enhancements, benefit changes, releases, and production issue resolution
ā¢ Participate in UAT planning and execution, including test case creation, test data validation, and defect triage
ā¢ Support modernization initiatives, including claims platform upgrades, PBM transitions, and data integrations
Cross-Functional Collaboration
ā¢ Act as a liaison between Pharmacy Operations, IT, Finance, Compliance, and vendors
ā¢ Communicate complex pharmacy and claims concepts clearly to technical and non-technical stakeholders
Required Qualifications
ā¢ 5+ years of experience as a Data Analyst, Systems Analyst, or Business Analyst in a health insurance payer or PBM environment
ā¢ Strong hands-on experience with Rx claims data and pharmacy benefit management
ā¢ Advanced proficiency in SQL and experience working with large healthcare datasets
ā¢ Solid understanding of pharmacy benefit design, claims adjudication logic, and payer operations
ā¢ Experience supporting production issues, audits, and regulatory reporting
ā¢ Excellent communication skills with the ability to work across technical and business teams
Preferred Qualifications
ā¢ 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
Apply Now
Apply Now
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
ā¢ Analyse end-to-end Rx claims adjudication workflows, including eligibility, benefit design, formulary, pricing, accumulators, edits, prior authorization, and reversals
ā¢ Interpret and validate pharmacy benefit requirements such as copays, coinsurance, deductibles, OOP max, step therapy, quantity limits, and formulary tiers
ā¢ Support PBM integrations and data exchanges (e.g., eligibility files, claims feeds, rebates, encounter data)
ā¢ Perform root-cause analysis on claims payment issues, rejects, and member/provider escalations
ā¢ Ensure claims logic aligns with CMS, state Medicaid, and commercial regulatory requirements
Data Analysis & Reporting
ā¢ Query and analyze large Rx claims datasets using SQL and analytical tools to identify trends, anomalies, and financial impacts
ā¢ Develop and maintain operational, financial, and compliance reports related to pharmacy utilization, spend, and claims accuracy
ā¢ Support audits, reconciliations, and compliance reporting (e.g., CMS encounters, PDEs, state reporting)
ā¢ Validate data accuracy across upstream and downstream systems
Systems & Business Analysis
ā¢ Gather and document business requirements and translate them into functional specifications, data mappings, and system rules
ā¢ Partner with IT and vendors to support system enhancements, benefit changes, releases, and production issue resolution
ā¢ Participate in UAT planning and execution, including test case creation, test data validation, and defect triage
ā¢ Support modernization initiatives, including claims platform upgrades, PBM transitions, and data integrations
Cross-Functional Collaboration
ā¢ Act as a liaison between Pharmacy Operations, IT, Finance, Compliance, and vendors
ā¢ Communicate complex pharmacy and claims concepts clearly to technical and non-technical stakeholders
Required Qualifications
ā¢ 5+ years of experience as a Data Analyst, Systems Analyst, or Business Analyst in a health insurance payer or PBM environment
ā¢ Strong hands-on experience with Rx claims data and pharmacy benefit management
ā¢ Advanced proficiency in SQL and experience working with large healthcare datasets
ā¢ Solid understanding of pharmacy benefit design, claims adjudication logic, and payer operations
ā¢ Experience supporting production issues, audits, and regulatory reporting
ā¢ Excellent communication skills with the ability to work across technical and business teams
Preferred Qualifications
ā¢ 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
Apply Now
Apply Now