Data Analyst

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

Required Qualifications

• 5 years of experience as a Data Analyst Systems 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 te

Key Skills
Data Analytics,Microsoft Access,SQL,Power BI,R,Data Visualization,Tableau,Data Management,Data Mining,SAS,Data Analysis Skills,Analytics
Employment Type : Full Time
Experience: years
Vacancy: 1