Pharmacy Network & Pricing Configuration Analyst

Abarca Health•Phoenix, AZ

7d•Hybrid

About The Position

In a few words… Abarca is igniting a revolution in healthcare. We built our company on the belief that with smarter technology we are redefining pharmacy benefits, but this is just the beginning… As a Pharmacy Network & Pricing Configuration Analyst, you will be responsible for pharmacy network and pricing configuration within our Pharmacy Benefit Management (PBM) environment. This role is focused on configuring, validating, and supporting pharmacy network participation and pricing logic for Medicare, Medicaid, Commercial, and Employer clients, ensuring accurate claims adjudication and compliance with regulatory and client requirements. The fundamentals for the job… Serve as the primary support for pharmacy network and pricing configuration, including network setup, contracted rates, and pricing rules for new client implementations and existing plan changes. Configure and maintain pricing logic to ensure accurate claims adjudication aligned with client documentation and contractual agreements. Support configuration changes related to pharmacy network participation and pricing structures across multiple lines of business. Perform unit testing focused on network and pricing configuration, validating adjudication outcomes against expected pricing and network rules. Research and resolve claims adjudication issues related to network participation or pricing discrepancies, including root cause analysis, impact assessment, and corrective actions. Provide first-tier triage support for network and pricing-related claims processing issues within defined SLAs/SLOs. Collaborate with configuration peers, adjudication, product, and operational teams to execute accurate network and pricing configuration solutions. Take ownership of project-based configuration work, ensuring timelines and deliverables are met. Identify network and pricing functionality required to meet client outcomes and support implementation execution. Develop and maintain an in-depth understanding of Darwin (proprietary adjudication platform) logic related to pharmacy network and pricing configuration. Stay current with Medicare, Medicaid, and state regulatory requirements, ensuring network and pricing configurations remain compliant. Provide consultation and peer review for network and pricing configuration practices. Support the Sr. Analyst in documenting client plan standards, configuration processes, and operational procedures. Evaluate network and pricing configuration workflows and recommend process improvements.

Requirements

Associate or bachelor's degree. (In lieu of a degree, equivalent relevant work experience may be considered.)
3+ years of hands-on experience in PBM Pharmacy Network & Pricing configuration, including pharmacy network setup and pricing rule implementation.
2+ years of experience within PBM operations, such as configuration, adjudication support, pharmacy networks, or Medicare-related functions.
Experience using SQL and Excel to validate network participation and pricing outcomes in claims adjudication.
Strong analytical skills with the ability to identify pricing and network-related issues and determine root cause.
Excellent oral and written communication skills.
Ability to collaborate effectively across technical and operational teams.
We are proud to offer a flexible hybrid work model which will require certain on-site workdays (Puerto Rico Location Only).
This position requires availability to work in a specified time zone or working schedule, accommodating the business needs of our clients and team members.
This position may require availability for on-call hours, including evenings, weekends, and holidays, to promptly address emergent issues or provide necessary support as dictated by operational demands (if applicable).

Nice To Haves

Experience with pharmacy network contracting, pricing models, or MAC list management.
Experience in a healthcare non-retail pharmacy or PBM setting.
Prior experience working directly with Darwin or similar adjudication platforms.

Responsibilities

Serve as the primary support for pharmacy network and pricing configuration, including network setup, contracted rates, and pricing rules for new client implementations and existing plan changes.
Configure and maintain pricing logic to ensure accurate claims adjudication aligned with client documentation and contractual agreements.
Support configuration changes related to pharmacy network participation and pricing structures across multiple lines of business.
Perform unit testing focused on network and pricing configuration, validating adjudication outcomes against expected pricing and network rules.
Research and resolve claims adjudication issues related to network participation or pricing discrepancies, including root cause analysis, impact assessment, and corrective actions.
Provide first-tier triage support for network and pricing-related claims processing issues within defined SLAs/SLOs.
Collaborate with configuration peers, adjudication, product, and operational teams to execute accurate network and pricing configuration solutions.
Take ownership of project-based configuration work, ensuring timelines and deliverables are met.
Identify network and pricing functionality required to meet client outcomes and support implementation execution.
Develop and maintain an in-depth understanding of Darwin (proprietary adjudication platform) logic related to pharmacy network and pricing configuration.
Stay current with Medicare, Medicaid, and state regulatory requirements, ensuring network and pricing configurations remain compliant.
Provide consultation and peer review for network and pricing configuration practices.
Support the Sr. Analyst in documenting client plan standards, configuration processes, and operational procedures.
Evaluate network and pricing configuration workflows and recommend process improvements.