Pharmacy Network – Pricing Configuration Analyst
Abarca Health
full-time
Posted on:
Location Type: Hybrid
Location: 🇺🇸 United States
Visit company websiteJob Level
Mid-LevelSenior
Tech Stack
SQL
About the role
- Serve as the primary support for pharmacy network and pricing configuration, including network setup, contracted rates, and pricing rules for new client implementations and existing plan changes.
- Configure and maintain pricing logic to ensure accurate claims adjudication aligned with client documentation and contractual agreements.
- Support configuration changes related to pharmacy network participation and pricing structures across multiple lines of business.
- Perform unit testing focused on network and pricing configuration, validating adjudication outcomes against expected pricing and network rules.
- Research and resolve claims adjudication issues related to network participation or pricing discrepancies, including root cause analysis, impact assessment, and corrective actions.
- Provide first-tier triage support for network and pricing-related claims processing issues within defined SLAs/SLOs.
- Collaborate with configuration peers, adjudication, product, and operational teams to execute accurate network and pricing configuration solutions.
- Take ownership of project-based configuration work, ensuring timelines and deliverables are met.
- Identify network and pricing functionality required to meet client outcomes and support implementation execution.
- Develop and maintain an in-depth understanding of Darwin (proprietary adjudication platform) logic related to pharmacy network and pricing configuration.
- Stay current with Medicare, Medicaid, and state regulatory requirements, ensuring network and pricing configurations remain compliant.
- Provide consultation and peer review for network and pricing configuration practices.
- Support the Sr. Analyst in documenting client plan standards, configuration processes, and operational procedures.
- Evaluate network and pricing configuration workflows and recommend process improvements.
Requirements
- Associate or bachelor’s degree. (In lieu of a degree, equivalent relevant work experience may be considered.)
- 3+ years of hands-on experience in PBM Pharmacy Network & Pricing configuration, including pharmacy network setup and pricing rule implementation.
- 2+ years of experience within PBM operations, such as configuration, adjudication support, pharmacy networks, or Medicare-related functions.
- Experience using SQL and Excel to validate network participation and pricing outcomes in claims adjudication.
- Strong analytical skills with the ability to identify pricing and network-related issues and determine root cause.
- Excellent oral and written communication skills.
- Ability to collaborate effectively across technical and operational teams.
- This position requires availability to work in a specified time zone or working schedule, accommodating the business needs of our clients and team members.
- This position may require availability for on-call hours, including evenings, weekends, and holidays, to promptly address emergent issues or provide necessary support as dictated by operational demands (if applicable).
Benefits
- Flexible hybrid work model which will require certain on-site workdays (Puerto Rico Location Only).
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
PBM Pharmacy Network configurationPricing rule implementationSQLExcelClaims adjudicationRoot cause analysisNetwork setupPricing logic maintenanceUnit testingProcess improvement
Soft skills
Analytical skillsOral communicationWritten communicationCollaborationOwnershipProblem-solvingTriage supportConsultationPeer reviewTime management
Certifications
Associate degreeBachelor's degree