PBM Operations Associate

Summary

Join Rightway's Operations team as a PBM Operations Analyst and contribute to the configuration, testing, and maintenance of benefits and claims adjudication rules within the claims platform. Collaborate with various stakeholders to ensure eligibility and accumulator functions align with requirements. Oversee vendor feeds and third-party integrations, troubleshooting issues to meet timely deliverables. Configure benefits in the claims adjudication platform, developing and executing test scenarios for accuracy. Research and troubleshoot inquiries related to claims adjudication, accumulators, and eligibility, while maintaining updated documentation. This role reports to the Director, Claims & Data Operations.

Requirements

1-3 years of PBM experience in claims or benefit configuration

Responsibilities

• Support the execution of all eligibility and accumulator operations and interfaces from implementation through ongoing operations and maintenance
• Serve as day-to-day contact for all eligibility and accumulator needs
• Collaborates with technology, account management, benefit administration, and other internal stakeholders to ensure that eligibility and accumulator functions are implemented and operating in accordance with requirements
• Oversee all downstream vendor feeds (i.e. ID card fulfillment), third party integrations (i.e. health plans, TPAs) and ensures all deliverables are met timely and troubleshoots issues
• Configures benefits into the claim adjudication platform, including benefit inclusions/exclusions copay, accumulator, and other benefit parameters
• Develops and executes on test scenarios to ensure accuracy of benefit setup both at initial setup and conducts ongoing monitoring and regression testing. Works to correct all identified defects
• Performs research and troubleshoots inquiries or issues related to claims adjudication, accumulators, and eligibility
• Ensures all documentation regarding setup and internal controls is always up to date

Preferred Qualifications

• Bachelor’s degree preferred
• Relevant experience considered for exceptional candidates
• Pharmacy Technician or related experience highly desirable