Analyst, Adjudication
About The Position
The Adjudication Analyst is responsible for supporting the implementation, maintenance, analysis, and quality assurance of ConnectiveRx pharmaceutical affordability (copay) programs. The candidate will be accountable for program set-ups and maintenance. This role performs quality control on program setups and updates, investigates adjudication outcomes and data discrepancies, and applies business rules consistently to ensure operational accuracy and program integrity. The Adjudication Analyst works independently on routine tasks and collaborates with Senior Analysts or Leads on complex issues, contributing to issue resolution and continuous improvement within a fast-paced environment.
Requirements
- Bachelor’s degree from 4-year college or university or equivalent experience required
- Minimum 2-4 yrs of pharmacy technician/adjudication experience.
- Knowledge of healthcare operations claims processing, pharmaceutical affordability programs, or other rules-driven operational environments.
- Understanding of quality control methodologies, issue investigation, and root-cause analysis.
- Familiarity with interpreting, applying, and questioning documented business rules.
- Awareness of operational standards and documentation.
- Intermediate skill level in Microsoft office applications
- Proficient analytical and problem-solving skills with the ability to conduct independent investigations. Must conduct research by gathering information, identifying patterns, establish relationships between data points, draw logical conclusions based on data
- Excellent attention to detail and accuracy in data analysis, quality checks, and documentation.
- Proficient ability to listen actively and effective written and verbal communications skills for conveying findings, issues, and recommendations.
- Understands the need to share only relevant information.
- Ability to adapt to different audiences, ensuring that the message is clearly articulated.
- Detail oriented; analytical, organized, multitasking capabilities, time management skills, quick learner, ability to work accurately and collaboratively both independently and as part of a team.
Nice To Haves
- Prior experience performing quality checks, operational analysis, or investigative work preferred
Responsibilities
- Assists in the set-up and maintenance of affordability programs and other ConnectiveRx adjudicated program offerings.
- Respond to and resolve business rule questions or concerns escalated by internal teams or adjudicator partners, escalating complex issues as appropriate.
- Conduct quality control reviews on new program setups and requested updates to ensure accuracy, consistency, and adherence to established rules and standards
- Access, analyze, and interpret program and adjudication data to evaluate rule functionality; investigate discrepancies, anomalies, or incorrect outcomes and document findings
- Develop and maintain a working knowledge of adjudication claims engines and networks, including differences in system logic across multiple adjudicators. Works proficiently within various tools (Salesforce, ManageEngine, CRx systems) to fulfill requests.
- Support documentation updates and process improvements. Primarily responsible for maintaining SOPs, work instructions, job aids, tracking logs and spreadsheets.
- Participate in regularly scheduled adjudication calls, ad hoc meetings, and internal discussions; engage in training sessions as required to support operational objectives.
Benefits
- medical, dental, vision, life, and disability insurance
- 401(k) plan, with employer contributions where applicable
- flexible paid time off (PTO) policy for exempt employees, covering sick days, personal days, and vacations
- eight standard company holidays and three floating holidays annually
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
