PBM Operations Associate

🔥 5 minutes ago

🐊 Florida – Remote

🐊 Florida – Remote

💵 $65k - $85k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

⚙️ Operations

🚫👨‍🎓 No degree required

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

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Rightway

WebsiteLinkedInAll Job Openings

201 - 500 employees

🏥 Healthcare

⚕️ Healthcare Insurance

☁️ SaaS

💰 $100M Series C on 2021-03

Healthcare • Healthcare Insurance • SaaS

Rightway is a healthcare company focused on providing care navigation and pharmacy benefits management solutions. It specializes in helping employers and health systems lower healthcare costs and improve outcomes through personalized, proactive clinical support and transparent pharmacy benefits management. Rightway offers a human-first approach, providing real-time, one-on-one support to members to help them make better healthcare decisions and navigate the complexities of healthcare systems. The company aims to reduce healthcare costs while improving employee satisfaction with healthcare services.

📋 Description

• Review client benefit design documentation for completeness and accuracy, flagging open items and partnering with implementation and client success to resolve gaps • Configure client benefit designs in the claims adjudication platform, including plan parameters, copay structures, inclusions and exclusions, and utilization management edits • Support new client implementations and mid-year plan changes • Develop and execute test claim scenarios to validate benefit setup before go-live • Perform ongoing monitoring and regression testing after changes • Research, document, and correct identified defects through resolution • Research and resolve inquiries related to claims adjudication and benefit configuration • Partner with client success to communicate findings and remediation steps • Work cross-functionally with product, client success, implementation, and formulary teams • Maintain audit-ready documentation of benefit setup, testing evidence, and internal controls • Track implementation and plan-change work, keeping status, ownership, and deadlines current

🎯 Requirements

• Bachelor’s degree preferred; relevant experience considered for exceptional candidates • 1-3 years of PBM experience in claims adjudication, benefit configuration, or testing/QA • Pharmacy Technician certification or related pharmacy experience highly desirable • Strong attention to detail with the ability to trace a claim outcome back to its configuration driver • Comfortable navigating ambiguity and working from incomplete requirements • Able to ask the right questions and exercise sound judgment when documentation does not cover every scenario • Comfortable working in Excel, Smartsheet, and claims platforms • Able to manage multiple client deliverables against firm deadlines • Clear written communication and documentation skills • Ability to keep stakeholders informed without being prompted

🏖️ Benefits

• Bonus • Equity • Equal Opportunity Employer and inclusive culture • Rightway health guides and human experts for members (company product/service description, not an employee benefit)