PBM Claims Adjudication Specialist

9 hours, 59 minutes 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

Senior Implementation Associate

DoorDash 10K-50K Air Freight & Logistics

DoorDash is hiring a Senior Implementation Associate to onboard and launch New Verticals merchants, manage the post-contract journey, and help build scalable implementation processes for emerging local-commerce categories.

9 hours, 29 minutes ago

Procure-to-Pay Buyer [2635-216243]

LevelUp 51-250 Internet Software & Services

LevelUp is hiring three fully remote Procure-to-Pay Buyers in the Philippines to own procurement activities, vendor relationships, contracts, and savings initiatives for assigned business functions.

AWS GCP NetSuite
9 hours, 44 minutes ago

Content Rights & Operations Coordinator

PlayOn is hiring a part-time Content Rights & Operations Coordinator to support MaxPreps Social with third-party content permissions, rights documentation, brand protection, analytics tagging, and social publishing operations.

Instagram API TikTok
9 hours, 59 minutes ago

Safety Coordinator

Fetch Package 251-1K Air Freight & Logistics

Fetch is hiring a Safety Coordinator to support Health, Safety, and Environmental programs across warehouse, transportation, and site operations by strengthening compliance, incident prevention, and a proactive safety culture.

Dart
9 hours, 59 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