Analyst, Adjudication

This is a fully remote position, open to applicants in New Jersey.

📋 Description

• Assist with the establishment and upkeep of affordability programs and other adjudicated offerings from ConnectiveRx.

• Address and resolve inquiries or concerns regarding business rules that have been escalated by internal teams or adjudicator partners, escalating more complex issues as necessary.

• Perform quality control reviews on newly set up programs and requested modifications.

• Access, analyze, and interpret program and adjudication data to assess the functionality of rules.

• Investigate discrepancies, anomalies, or incorrect results and document the findings.

• Develop and maintain a solid understanding of adjudication claims engines and networks, including the distinctions in system logic among various adjudicators.

• Work effectively within Salesforce, ManageEngine, and CRx systems.

• Support updates to documentation and contribute to process enhancements.

• Maintain standard operating procedures (SOPs), work instructions, job aids, tracking logs, and spreadsheets.

• Participate in scheduled adjudication calls, ad hoc meetings, internal discussions, and necessary training sessions.

⛳️ Requirements

• A Bachelor’s degree from a four-year college or university, or equivalent experience is required.

• A minimum of 2-4 years of experience as a pharmacy technician or in adjudication is required.

• Previous experience performing quality checks, operational analysis, or investigative work is preferred.

• Knowledge of healthcare operations, claims processing, pharmaceutical affordability programs, or other rules-driven operational environments is essential.

• Understanding of quality control methodologies, issue investigation, and root-cause analysis is necessary.

• Familiarity with interpreting, applying, and challenging documented business rules is required.

• Awareness of operational standards and documentation practices is important.

• Intermediate proficiency in Microsoft Office applications is expected.

• Strong analytical and problem-solving skills with the ability to conduct independent investigations are required.

• Ability to research by gathering information, identifying patterns, establishing relationships between data points, and drawing logical conclusions based on the data is necessary.

• Excellent attention to detail and accuracy in data analysis, quality checks, and documentation is crucial.

• Proficient listening skills and effective written and verbal communication capabilities are essential.

• Ability to share only pertinent information is required.

• Capability to adapt to different audiences and clearly convey messages is important.

• Detail-oriented, analytical, organized, capable of multitasking, managing time effectively, and quick-learning skills are necessary.

• Ability to work accurately and collaboratively, both independently and as part of a team, is required.

• Must be willing to travel to CRx offices as needed, per supervisor requests.

• Must be open to traveling to adjudicator locations when necessary.

🏝️ Benefits

• Opportunities for bonuses (or commissions).

• Medical, dental, vision, life, and disability insurance.

• 401(k) plan with employer contributions where applicable.

• Flexible paid time off (PTO) policy for exempt employees, covering sick days, personal days, and vacations.

• Eight standard company holidays each year.

• Three floating holidays each year.