Claims Technical Analyst, Sr.

Our work matters. We help people get the medicine they need to feel better and live well.  We do not lose sight of that. It fuels our passion and drives every decision we make.

Job Posting Title

Claims Technical Analyst, Sr.Job Description

The Senior Claims Technical Analyst is responsible for serving as the claims analysis resource for assigned operations teams. This role is responsible for performing complex and escalated client, member and pharmacy remediation analysis caused by errors coded into the RxClaim claims processing system. This role is also responsible for providing training and mentorship to Claims Technical Analysts and Associate Analysts, along with leading process improvement and technology uplift efforts for department level applications.

Responsibilities

• Serve as lead Analyst for complex and/or escalated analysis requests; coordinate requests from internal and external clients and establish timelines, as well as presenting results
• Train Claims Technical Analysts and Associate Analysts on specific job functions; maintain training material and present materials in shadowing and classroom settings
• Review, perform root cause analysis, and monitor system defects on escalated RxClaim system issues; diagnose claim issues, assess claim trends, develop solutions and initiate appropriate claim resolution strategies
• Partner with cross functional teams to maintain, troubleshoot and improve analysis tools (RxClaim, Query tool requirements and Claims Reprocessing Tool Mechanism) and processes
• Develop and perform documented test case scenarios to support existing and newly developed tools and applications
• Other duties as assigned

Minimum Qualifications

• Bachelor’s degree in Business, Computer Science, IT, Mathematics, Finance or related area of study; or equivalent combination of education and/or relevant work experience; HS diploma or GED required
• 5 years of work experience in data analysis, including 2 years of experience working with claims data or systems
• Must be eligible to work in the United States without need for work visa or residency sponsorship

Additional Qualifications

• Strong negotiation and persuasion skills
• Strong verbal and written communication skills
• Ability to coordinate multiple projects/tasks simultaneously under strict timelines
• Strong analytical, problem solving, and decision-making skills
• Ability to work in fast-paced, collaborative team environment
• Advanced level Microsoft Excel Analysis Skills
• Ability to present complex material to a variety of audiences in plain language
• Experience utilizing advanced query tools and Structured Query Language (SQL)
• Experience with Medicare Part D and Centers for Medicare and Medicaid Services rules and regulations

Preferred Qualifications

• Training experience
• 2 years of experience working with RxClaim system

Minimum Physical Job Requirements

• Ability to work outside of Prime’s core business hours of 9:00 a.m. – 4:00 p.m. as needed
• Constantly required to sit, use hands to handle or feel, talk and hear
• Frequently required to reach with hands and arms
• Occasionally required to stand, walk and stoop, kneel, and crouch
• Occasionally required to lift and/or move up to 10 pounds and occasionally may be required to lift and/or move up to 25 pounds
• Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus

Reporting Structure

• Reports to a Supervisor or a Manager in PBM Operations

Potential pay for this position ranges from $64,700.00 - $97,100.00 based on experience and skills. Pay range may vary by 8% depending on applicant location.

Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, creed, color, religion, gender, sexual orientation, gender identity/expression, national origin, disability, age, genetic information, veteran status, marital status, pregnancy or related condition (including breastfeeding), expecting or parents-to-be, or any other basis protected by law. 

We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law.

Prime Therapeutics LLC is a Tobacco-Free Workplace employer.

Positions will be posted for a minimum of five consecutive workdays.