Role: Data Analyst
C2H
Location: Remote. The candidate may be expected to travel to NJ office 1-2 times in a month.
Must have experience on Rx claims and health insurance payer or PBM environment
Rx Claims & Pharmacy Domain
- Analyse end-to-end Rx claims adjudication workflows, including eligibility, benefit design, formulary, pricing, accumulators, edits, prior authorization, and reversals
- Interpret and validate pharmacy benefit requirements such as copays, coinsurance, deductibles, OOP max, step therapy, quantity limits, and formulary tiers
- Support PBM integrations and data exchanges (e.g., eligibility files, claims feeds, rebates, encounter data)
- Perform root-cause analysis on claims payment issues, rejects, and member/provider escalations
- Ensure claims logic aligns with CMS, state Medicaid, and commercial regulatory requirements
Data Analysis & Reporting
- Query and analyze large Rx claims datasets using SQL and analytical tools to identify trends, anomalies, and financial impacts
- Develop and maintain operational, financial, and compliance reports related to pharmacy utilization, spend, and claims accuracy
- Support audits, reconciliations, and compliance reporting (e.g., CMS encounters, PDEs, state reporting)
- Validate data accuracy across upstream and downstream systems
Systems & Business Analysis
- Gather and document business requirements and translate them into functional specifications, data mappings, and system rules
- Partner with IT and vendors to support system enhancements, benefit changes, releases, and production issue resolution
- Participate in UAT planning and execution, including test case creation, test data validation, and defect triage
- Support modernization initiatives, including claims platform upgrades, PBM transitions, and data integrations
Cross-Functional Collaboration
- Act as a liaison between Pharmacy Operations, IT, Finance, Compliance, and vendors
- Communicate complex pharmacy and claims concepts clearly to technical and non-technical stakeholders
Required Qualifications
-
5+ years of experience as a Data Analyst, Systems Analyst, or Business Analyst in a health insurance payer or PBM environment
- Strong hands-on experience with Rx claims data and pharmacy benefit management
- Advanced proficiency in SQL and experience working with large healthcare datasets
- Solid understanding of pharmacy benefit design, claims adjudication logic, and payer operations
- Experience supporting production issues, audits, and regulatory reporting
- Excellent communication skills with the ability to work across technical and business teams
Preferred Qualifications
- Experience with Rx claims platforms (e.g., Facets Rx, QNXT, RxClaim, MedImpact, Caremark, OptumRx)
Familiarity with CMS Part D, Medicaid pharmacy programs, and encounter/PDE reporting
Regards,
Manoj
Derex Technologies INC
Contact : 973-834-5005 Ext 206
All your information will be kept confidential according to EEO guidelines.
