PBM Data Analyst - Rx Claims : Remote
as it is a contract to Hire
Newark, NJ
Location: Hybrid - Travel to New Jersey office twice in a month.
NOTE: This is a 6 month contract-to-hire role, with the opportunity to work directly with the client after the contract period.
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
Required Qualifications
5 years of experience as a Data Analyst, Systems 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.
Please send me the below information with your docs and Word format resume
Full Name :
Contact #
Current Location with postal code:
Email ID:
May I know your Visa status:
LinkedIn, if so any :
Availability once confirmed for the project to start the project :
Last 4 digits SSN:
Skype ID:
Rate/hr on W2 All Inclusive:DOB (MM/ DD):
A Small write-up why thinks an ideal fit for the above role and years of exp on the below skills and client where you used:
PBM Environment :
Rx claims
2-3 Professional Managerial Level References, if possible
Certifications if any kindly mention and do you have the certifications as mentioned above for this role
Best Time and Contact number we can reach you in business working hours:
Highest Education details with University Name, Year of Start, and Passout
Apply Now
Apply Now
Newark, NJ
Location: Hybrid - Travel to New Jersey office twice in a month.
NOTE: This is a 6 month contract-to-hire role, with the opportunity to work directly with the client after the contract period.
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
Required Qualifications
5 years of experience as a Data Analyst, Systems 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.
Please send me the below information with your docs and Word format resume
Full Name :
Contact #
Current Location with postal code:
Email ID:
May I know your Visa status:
LinkedIn, if so any :
Availability once confirmed for the project to start the project :
Last 4 digits SSN:
Skype ID:
Rate/hr on W2 All Inclusive:DOB (MM/ DD):
A Small write-up why thinks an ideal fit for the above role and years of exp on the below skills and client where you used:
PBM Environment :
Rx claims
2-3 Professional Managerial Level References, if possible
Certifications if any kindly mention and do you have the certifications as mentioned above for this role
Best Time and Contact number we can reach you in business working hours:
Highest Education details with University Name, Year of Start, and Passout
Apply Now
Apply Now