Abarca Health is hiring a
PDE Analyst

Summary

Join Abarca in igniting a revolution in healthcare as a PDE Analyst, conducting investigations and resolving complex issues with strong analytical and communication skills.

Requirements

• Associate or bachelor’s degree. (In lieu of a degree, equivalent, relevant work experience may be considered.)
• 1+ years of combined or relevant work-related experience
• 2+ years of experience working with Medicare Part D claims, PDE, benefit configuration required; at least one year working directly with PDEs required
• Ability to spot patterns and discrepancies
• Experience applying financial acumen and analytical skills
• Ability to work in a high-growth, fast-paced, and complex business environment
• Manage multiple important investigations simultaneously
• Ability to think analytically and consider all client configurations, dive into the details, and know when to operate at each level
• Excellent oral and written communication skills

Responsibilities

• Locate, read, understand, and apply CMS guidance to your processes as necessary
• Understand and explain Medicare Part D concepts like TrOOP, PLRO, defined standard benefit, member benefit phases, among others
• Analyze and resolve PDE errors. This includes identifying situations where reprocessing and adjustments are required
• Review PDEs to ensure accuracy and compliance with regulations
• Understand and execute quality assurance checks on PDE file submissions, as well as perform UAT for PDE-related enhancements
• Research and resolve Acumen audits
• Understand and explain general drug terminology like drug hierarchy, drug indicators like brand/generic, multi-source code, and how those may impact adjudication or PDE processing
• Able to research pharmacy claims and understand the difference between claims adjudication, benefit configuration, and plan set up
• Create and analyze reports, as well as compiling tracking, and monitoring to validate compliance with client and CMS guidance
• Identify and track defects or resolutions and provide timely follow up via CRM
• Request and review claim reprocessing results to ensure accuracy
• Stay up to date on CMS guidance related to Medicare Part D claims. Understand and reference said guidance when analyzing and resolving issues
• Identify and proactively suggest process improvements
• Document and provide solutions to technical and non-technical audiences

Benefits

• Flexible hybrid work model which will require certain on-site work days (Puerto Rico Location Only)
• Availability to work in a specified time zone or working schedule, accommodating the business needs of our clients and team members
• On-call hours, including evenings, weekends, and holidays, to promptly address emergent issues or provide necessary support as dictated by operational demands (if applicable)