Claims Adjudication Analyst

Cumberland, RI 02864

Post Date: 02/21/2018 Job ID: 26050 Category: Professional

Job Summary:

As a Claims Adjudication Analyst, you will be responsible for ensuring that all required third party settings are processed accurately and in a timely fashion for new and existing third party plans into the retail pharmacy application.

As a part of the Payer Relations team, the Claims Adjudication Analyst allows you to analyze third party programs, and investigate and resolve systemic issues relative to claims processing that interfaces with stores, providers, patients, pricing and financial impacts to the company.

Job Duties:
  • Perform extensive testing and documentation to ensure accurate claims adjudication and compliance with pharmacy standards and payer specification sheets.
  • Receiving third party program contract updates and creating or modifying third party plan configurations necessary to comply with industry standards, contract agreements and state and federal regulations.
  • Working with Pharmacy Application Development teams in Information Systems (IS) to provide third party claims adjudication support for all system related issues or enhancements including defining business scenarios and testing procedures.
  • Analyzing production issues for any potential causes and recreating all known defects in test environments to assist development.
  • Working cross-functionally within the department to provide quality assurance for Performance, Contract Administration, Industry Relations and other departments by executing various scenarios affecting claims adjudication and provide detailed analysis of the results.

Required Qualifications:
  • Verifiable High School diploma or GED is required.
  • 1 + years of experience using Microsoft Word and Excel.

Preferred Qualifications:
  • Bachelor's degree preferred.
  • 1 + years of related experience in pharmacy, PBM, or insurance.
  • Previous experience with business-to-business, interdepartmental, or customer interactions
  • Experience working in a high volume environment (ie. Call center, pharmacy technician)
  • Experience with SQL or Access.

For more information, please contact A-Line Staffing at 877-782-3334.


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