Data Analyst Pharmacy Claims(Only on W2)

Role: Data Analyst

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