Data Analyst

Role: Data Analyst

Location: Remote.

Note: Only on W2

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

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