- Pharmacy Benefit Manager System Configuration setup and maintenance for pharmacy benefits, networks and pricing for Medicare, Medicaid, Commercial and Employer groups.
- Perform testing to confirm configuration set-up or changes are processing as expected as defined in the client documentation.
- Develop in-depth understanding of Darwin (proprietary adjudication platform) system logics to ensure benefit designs are configured to meet client request.
- Provide timely first-tier triage support to verify and analyze pharmacy claims processing case research referred for validation.
- Support pharmacy claims adjudication research, analysis, identification of root cause, impact analysis determination and corrective action.
- Responsible for daily tracking and monitoring of assigned requests to ensure due dates are met.
- Utilize critical thinking and organizational skills to ensure all work is performed with the highest level of quality, accuracy and delivered timely.
- Associate or bachelor's degree. (In lieu of a degree, equivalent relevant work experience may be considered.)
- 3+ years of work-related experience.
- Experience working with SQL and Excel tools.
- Ability to establish good interpersonal skills.
- Excellent oral and written communication skills.
- We are proud to offer a flexible hybrid work model which will require certain on-site work days (Puerto Rico Location Only).
- Experience in a healthcare non-retail pharmacy setting.
- Experience related to Pharmacy Benefit Manager Operations, Member Services, Pharmacy Networks, Fulfillment, Call Center, and Medicare.
- Must be able to access and navigate each department at the organization's facilities.
- Sedentary work that primarily involves sitting/standing.
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Darwin Claim Analyst - Miami, United States - Abarca Health
Description
What you'll do
In a few words...
Abarca is igniting a revolution in healthcare. We built our company on the belief that with smarter technology we are redefining pharmacy benefits, but this is just the beginning...
The Darwin Claims Administration team provides high quality services to clients and beneficiaries and meets that standard by configuring timely and accurate updates related to plan benefit, pricing, and network changes and beyond. The Darwin Claims Administration team handles all claims verifications, daily configuration set-up and maintenance, and related special projects, issue management and research for benefit configuration.
As a Darwin Claims Analyst, you will be responsible for implementing new and updating existing benefit plan setups for Medicare, Medicaid, Commercial and Employer clients. Also, you will review client configuration requests, identify, and define their needs and requirements, determine the best operational approach, and perform setup in the Pharmacy Benefit Manager system. The position also requires that you perform client configuration setup testing on all plan benefit design changes into a production scenario to ensure proper and accurate configuration for claims processing and adjudication. Additionally, you will provide first level triage for operational issues, analyze, and identify solutions to resolve issues in configuration setup, claims processing and other operational gaps.
The fundamentals for the job...
What we expect of you
The bold requirements...
Nice to haves...
Physical requirements...
At Abarca we value and celebrate diversity. Diversity, equity, inclusion, and belonging are guiding principles of Abarca and ensure Abarca's workforce reflects the communities it serves. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.
Abarca Health LLC is an equal employment opportunity employer and participates in E-Verify. "Applicant must be a United States' citizen. Abarca Health LLC does not sponsor employment visas at this time"
The above description is not intended to limit the scope of the job or to exclude other duties not mentioned. It is not a final set of specifications for the position. It's simply meant to give readers an idea of what the role entails.
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