PBM Claims Adjudication Specialist

1 week, 2 days ago
Full-time
Senior
Operations
AffirmedRx

AffirmedRx

AffirmedRx is a pharmacy benefit management company dedicated to enhancing healthcare outcomes through integrity, clarity, and trust. They prioritize making pharmacy benefits easy to understand, accessible, and aligned with the best interests of employ...

Insurance
1-10

Description

  • Design, build, configure, test, and validate client eligibility files based on benefit plans and client requirements.
  • Design and maintain accumulator files covering deductibles, out-of-pocket amounts, and benefit data.
  • Apply PBM claims adjudication expertise to file design, testing, troubleshooting, and issue resolution.
  • Serve as a subject-matter expert on adjudication logic, NCPDP standards, and claims processing rules.
  • Develop and maintain scripts and automations for file building, testing, and validation.
  • Configure and manage SFTP connections for secure client file transmission.
  • Investigate and resolve eligibility, accumulator, and transmission discrepancies before they affect clients or members.
  • Support change control for client files, layouts, and related production systems.
  • Collaborate with Business Analysts, ETL developers, File Management Analysts, and Data Operations colleagues on complex client issues.

Requirements

  • Bachelor’s degree in a related field or equivalent experience.
  • Deep, hands-on experience with PBM claims adjudication and the interaction between claims, eligibility, and accumulator data.
  • 7+ years of direct PBM experience building and maintaining client eligibility and accumulator files.
  • Strong knowledge of NCPDP standards, claims processing rules, and benefit design.
  • Experience setting up, configuring, and managing SFTP connections.
  • Excellent troubleshooting and problem-solving skills with strong attention to detail.
  • Experience with the RxSense platform is preferred.
  • Ability to work independently and collaboratively in a small team.
  • Mission-driven, supportive approach aligned with trust, accountability, and innovation.
  • Willingness to travel 10%–20%.

Benefits

  • Competitive compensation with health, dental, vision, and other benefits.
  • Opportunity to contribute to change in the pharmacy benefits management industry and improve patient outcomes.
  • Culture focused on employee growth, collaboration, and team success.
  • Remote work environment with expectations for a professional, distraction-free workspace.

Interested in this position?

Apply directly on the company website

Apply Now

Similar Roles

Operations Specialist

JOLT is hiring an Operations Specialist to support the technical operations, maintenance, commissioning, and customer experience of its EV charging network in the United States.

9 hours, 23 minutes ago

Financial Operations Specialist

Tenstorrent 251-1K Internet Software & Services

Tenstorrent is seeking a remote U.S.-based Finance Operations Specialist to improve core finance processes, controls, automation, and cross-functional operating efficiency as the company scales its AI platform.

9 hours, 38 minutes ago

Virtual Operations & Marketing Assistant

Assist World IT Services

Assist World is seeking a remote operations and marketing generalist to integrate systems, build the customer funnel, and support day-to-day operations for a growing food business.

Email Marketing Mailchimp Social Media Marketing
10 hours, 8 minutes ago

TMF Lead/Senior TMF Lead

Precision For Medicine 1K-5K Pharmaceuticals

Precision for Medicine is hiring a remote TMF Lead/Senior TMF Lead in Serbia, Poland, Hungary, Romania, or Slovakia to oversee eTMF delivery, compliance, and continuous improvement across clinical studies.

10 hours, 8 minutes ago

You're on a roll! Sign up now to keep applying.

Sign Up

Already have an account? Log in

Used by 14,729+ remote workers