Abarca Health

A different kind of PBM on a mission to make healthcare seamless & personalized for everyone. #PBMAwesome

Senior Pharmacy Network Configuration Analyst

AnalystAnalystFull TimeRemoteTeam 501-1,000Since 2008H1B No SponsorCompany SiteLinkedIn

Location

Florida

Posted

53 days ago

Salary

Not specified

Bachelor Degree6 yrs expExperience acceptedEnglishSQL

Job Description

• 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.

Job 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).

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