PBM Claims Adjudication Specialist

Job not on LinkedIn

🔥 0 minutes ago

🐎 Kentucky – Remote

🐎 Kentucky – Remote

⏰ Full Time

🟠 Senior

🔴 Lead

👻 Ghost score 19%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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AffirmedRx, a Public Benefit Corporation

WebsiteLinkedInAll Job Openings

11 - 50 employees

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

AffirmedRx is a Public Benefit Corporation dedicated to transforming the pharmacy benefit management (PBM) industry. Focused on transparency, patient-centric care, and innovative solutions, AffirmedRx aims to overcome the complexities and opacity that traditionally plague the PBM sector. By empowering individuals and organizations, the company provides clarity and unwavering support in navigating pharmacy benefits. AffirmedRx stands for integrity and partnership, striving to offer a healthier and more informed pharmacy benefits experience while boldly tackling the rising costs of healthcare and pharmaceuticals.

📋 Description

• Design, build, and configure new client eligibility files based on client-specific requirements and benefit plan designs • Translate client eligibility rules and benefit structures into accurate file specifications and processing logic • Test and validate eligibility files before production go-live • Design, build, and maintain accumulator files reflecting member deductible, out-of-pocket, and benefit accumulator data • Ensure accumulator logic aligns with plan design and claims adjudication rules • Investigate and resolve accumulator data discrepancies • Apply PBM claims adjudication knowledge to file design, testing, and issue resolution • Serve as the team’s expert on adjudication logic, NCPDP standards, and claims processing rules • Partner with Business Analyst, ETL Developer/File Management Analyst, and Data Operations team members on complex client issues • Develop automations and scripts for file build, testing, and validation • Reduce manual work through coding and automation • Maintain and improve existing automations as client needs and file formats evolve • Configure and manage SFTP connections for client file transmissions • Ensure secure and reliable file transfers • Troubleshoot SFTP connectivity and transmission issues • Maintain accurate eligibility and accumulator data across clients • Identify and resolve discrepancies before client- or member-facing issues arise • Support change control for client files, layouts, and related production systems • Report to the Manager, Data Operations

🎯 Requirements

• Bachelor’s degree in a related field, or equivalent experience • Deep, hands-on experience with PBM claims adjudication, including how claims process, adjudicate, and interact with eligibility and accumulator data • 7+ years of direct PBM experience building and maintaining client eligibility files and accumulator files • Strong knowledge of NCPDP standards, claims processing rules, and benefit design as they relate to file build and testing • Experience with SFTP setup, configuration, and management for secure client file transmission • Excellent troubleshooting and problem-solving skills • High attention to detail • Comfortable working independently and as part of a small, collaborative team • Mission-driven, humble, and supportive; holds high standards while fostering learning rather than blame • Aligns with AffirmedRx values, promoting trust, accountability, and innovation • Willingness to travel (10%-20%) • Experience working with the RxSense platform is a significant plus

🏖️ Benefits

• Competitive compensation, including health, dental, vision and other benefits • Opportunity to impact industry change in the pharmacy benefits management space while delivering high-quality patient outcomes • Culture where people thrive and team success supports business success • Remote work arrangement