Senior Pharmacy Network Configuration Analyst
Abarca Health
full-time
Posted on:
Location Type: Remote
Location: Florida • United States
Visit company websiteExplore more
Job Level
Tech Stack
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 requirements.
- Support configuration changes related to pharmacy network participation and pricing structures across multiple lines of business.
- Perform unit testing to validate adjudication outcomes against expected network and pricing rules.
- Perform Quality Control and Quality Assurance reviews to ensure accuracy and consistency within network and pricing configuration processes.
- Participate as needed in UAT testing for product enhancements/updates to confirm operational and business user acceptance.
- Research and resolve claims adjudication issues related to network participation and pricing discrepancies, including root cause analysis, impact assessment, and corrective actions.
- Provide first-tier triage support for network and pricing-related claims processing issues, ensuring performance aligned to SLAs/SLOs.
- Take ownership of project-based configuration work, ensuring timelines, deliverables, and outcomes are met.
- Collaborate across configuration, adjudication, product, and operational teams to execute accurate network and pricing solutions.
- Identify network and pricing functionality required to meet client outcomes and support implementation execution.
- Continuously develop and maintain an in-depth understanding of Darwin (proprietary adjudication platform) logic related to network and pricing configuration.
- Stay current with Medicare, Medicaid, and state regulatory requirements, ensuring configurations remain compliant.
- Provide consultation and peer review for network and pricing configuration practices and design standards.
- Support the Sr. Analyst in documenting client plan standards, configuration processes, and operational procedures.
- Evaluate network and pricing workflows and recommend process improvements that advance efficiency, consistency, and quality outcomes.
- Support onboarding and knowledge transfer by contributing to documentation and training resources as needed.
Requirements
- Associate or bachelor’s degree. (In lieu of a degree, equivalent relevant work experience may be considered.)
- 6+ years of hands-on experience in PBM Pharmacy Network & Pricing configuration, including pharmacy network setup and pricing rule implementation.
- 2+ years of experience using SQL and Excel to validate network participation and pricing outcomes in claims adjudication.
- Strong analytical skills with the ability to identify network/pricing issues, determine root cause, and drive corrective actions.
- Ability to collaborate effectively across technical and operational teams.
- Excellent oral and written communication skills.
- 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
- We are proud to offer a 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 & Tools
pharmacy network configurationpricing configurationclaims adjudicationunit testingquality controlquality assuranceroot cause analysisSQLExcelprocess improvement
Soft Skills
analytical skillscollaborationcommunicationproblem-solvingownershipconsultationdocumentationtrainingattention to detailadaptability