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
• 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
Required Qualifications
• 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
Preferred Qualifications
• 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
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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
Required Qualifications
• 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
Preferred Qualifications
• 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