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PBM Claims Adjudication Specialist

Location not listed · remote · Salary not listed

Role overview

AffirmedRx is on a mission to improve health care outcomes by bringing clarity, integrity, and trust to pharmacy benefit management. We are committed to making pharmacy benefits easy to understand, straightforward to access and always in the best interest of employers and the lives they impact. We accomplish this by bringing total clarity to business practices, leading with clinical approaches, and utilizing state-of-the-art technology.

Join us in improving health care outcomes for all! We promise to do what’s right, always.

Position Summary:

The PBM Claims Adjudication Specialist is a deeply technical, hands-on role responsible for building and maintaining client eligibility and accumulator files that ensure AffirmedRx’s data is always comprehensive, always accurate. Reporting to the Manager, Data Operations, this person develops new client eligibility files and accumulator files, builds coding automations to streamline file processing, and sets up and manages SFTP connections for secure client file transmission. Deep, hands-on PBM claims adjudication experience is required — this role exists because getting eligibility and accumulator data right requires someone who genuinely understands how claims adjudicate, not just how files are formatted. Experience working with the RxSense platform is a significant plus.

What you will do:

Client Eligibility File Development:

Design, build, and configure new client eligibility files based on client-specific requirements and benefit plan designs
Translate client eligibility rules and benefit structures into accurate file specifications and processing logic
Test and validate eligibility files prior to go-live to confirm accuracy before they reach production

Accumulator File Development & Management:

Design, build, and maintain accumulator files reflecting member deductible, out-of-pocket, and benefit accumulator data
Ensure accumulator logic aligns correctly with plan design and claims adjudication rules
Investigate and resolve discrepancies in accumulator data before they affect members or clients

Claims Adjudication Expertise & Application:

Apply deep, hands-on PBM claims adjudication knowledge to inform file design, testing, and issue resolution
Serve as the team’s go-to expert on adjudication logic, NCPDP standards, and claims processing rules
Partner with the Business Analyst, ETL Developer/File Management Analyst, and other Data Operations team members on complex client issues requiring adjudication expertise

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PBM Claims Adjudication Specialist

Role overview

Position Summary:

What you will do:

Client Eligibility File Development:

Accumulator File Development & Management:

Claims Adjudication Expertise & Application:

Coding Automation:

SFTP Setup & Management:

Data Accuracy & Ongoing Maintenance:

What you need:

What you get:

Note: