[Remote] RxClaim Data Analyst - Rx claims and health insurance payer or PBM environment (Only Visa Independent no C2C )
Note: The job is a remote job and is open to candidates in USA. Programmers.io is seeking an RxClaim Data Analyst with experience in Rx claims and health insurance payer or PBM environments. The role involves analyzing Rx claims workflows, supporting PBM integrations, and performing data analysis to ensure compliance and accuracy in pharmacy claims.
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
Skills
• 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
Company Overview
• IBM i is evolving. And so are we. It was founded in 2012, and is headquartered in Coppell, Texas, USA, with a workforce of 1001-5000 employees. Its website is https://programmers.io/.
Apply Now
Apply Now
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
Skills
• 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
Company Overview
• IBM i is evolving. And so are we. It was founded in 2012, and is headquartered in Coppell, Texas, USA, with a workforce of 1001-5000 employees. Its website is https://programmers.io/.
Apply Now
Apply Now