Data Analyst-Rx Claims & Pharmacy Domain
About The Position
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
Requirements
- 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
Nice To Haves
- 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
Responsibilities
- 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
- 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
- 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
- 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
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What This Job Offers
Career Level
Mid Level
Education Level
No Education Listed
