PDE Analyst

What you’ll do

In a few words…

Abarca is igniting a revolution in healthcare.  We built our company on the belief that with smarter technology we are redefining pharmacy benefits, but this is just the beginning…

As a PDE Analyst, you will be asked to conduct investigations and resolve complex issues, putting your strong analytical and communication skills to the test. In your role, you will be accountable for researching and successfully resolving PDE errors and rejections. You will work with new cases and acquire platform knowledge through independent study, as well as interaction with other team members. The ability to discuss technical logic, awareness of when to be detailed, and assurance evoked through understanding of our solutions and technology is essential in this position.

The fundamentals for the job…

• Locate, read, understand, and apply CMS guidance to your processes as necessary.
• Understand and explain Medicare Part D concepts like TrOOP, PLRO, defined standar benefit, member benefit phases, among others.
• Analyze and resolve PDE errors. This includes identifying situations where reprocessing and adjustments are required.
• Review PDEs to ensure accuracy and compliance with regulations.
• Understand and execute quality assurance checks on PDE file submissions, as well as perform UAT for PDE-related enhancements.
• Research and resolve Acumen audits.
• Understand and explain general drug terminology like drug hierarchy, drug indicators like brand/generic, multi-source code, and how those may impact adjudication or PDE processing.
• Able to research pharmacy claims and understand the difference between claims adjudication, benefit configuration, and plan set up.
• Create and analyze reports, as well as compiling tracking, and monitoring to validate compliance with client and CMS guidance.
• Identify and track defects or resolutions and provide timely follow up via CRM.
• Request and review claim reprocessing results to ensure accuracy.
• Stay up to date on CMS guidance related to Medicare Part D claims. Understand and reference said guidance when analyzing and resolving issues.
• Identify and proactively suggest process improvements.
• Document and provide solutions to technical and non-technical audiences.

What we expect of you

The bold requirements…   

• Associate or bachelor’s degree. (In lieu of a degree, equivalent, relevant work experience may be considered.)
• 1+ years of combined or relevant work-related experience.
• 2+ years of experience working with Medicare Part D claims, PDE, benefit configuration required; at least one year working directly with PDEs required.
• Ability to spot patterns and discrepancies.
• Experience applying financial acumen and analytical skills.
• Ability to work in a high-growth, fast-paced, and complex business environment.
• Manage multiple important investigations simultaneously.
• Ability to think analytically and consider all client configurations, dive into the details, and know when to operate at each level.
• Excellent oral and written communication skills.
• We are proud to offer a flexible hybrid work model which will require certain on-site work days (Puerto Rico Location Only).
• 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).

Nice to haves…

• Bilingual fluency in Spanish and English.

Physical requirements…

• Must be able to access and navigate each department at the organization’s facilities.
• Sedentary work that primarily involves sitting/standing.

At Abarca we value and celebrate diversity. Diversity, equity, inclusion, and belonging are guiding principles of Abarca and ensure Abarca’s workforce reflects the communities it serves.  We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.

Abarca Health LLC is an equal employment opportunity employer and participates in E-Verify. Abarca Health LLC does not sponsor employment visas at this time.

The above description is not intended to limit the scope of the job or to exclude other duties not mentioned. It is not a final set of specifications for the position. It’s simply meant to give readers an idea of what the role entails.

#LI-REMOTE #LI-JM1