PBM Operations Associate

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

📋 Description

• Review client benefit design documentation for thoroughness and precision, identifying outstanding items and collaborating with implementation and client success teams to address gaps.

• Configure client benefit designs within the claims adjudication platform, encompassing plan parameters, copay structures, inclusions and exclusions, as well as utilization management edits.

• Assist in the implementation of new client accounts and mid-year plan modifications.

• Develop and execute test claim scenarios to ensure benefit setups are validated prior to going live.

• Conduct ongoing monitoring and regression testing following any changes.

• Investigate, document, and rectify any identified defects until resolution is achieved.

• Research and address inquiries related to claims adjudication and benefit configuration.

• Collaborate with client success to share findings and outline remediation steps.

• Work collaboratively across departments, including product, client success, implementation, and formulary teams.

• Maintain audit-ready documentation of benefit setups, testing evidence, and internal controls.

• Monitor implementation and plan-change tasks, ensuring status, ownership, and deadlines are up to date.

⛳️ Requirements

• Bachelor’s degree preferred; relevant experience may be considered for outstanding candidates.

• 1-3 years of experience in PBM, specifically in claims adjudication, benefit configuration, or testing/QA.

• Pharmacy Technician certification or related pharmacy experience is highly desirable.

• Strong attention to detail, with the ability to trace claim outcomes back to their configuration drivers.

• Comfortable navigating uncertainty and working with incomplete requirements.

• Capable of asking pertinent questions and exercising sound judgment when documentation lacks coverage for all scenarios.

• Proficient in using Excel, Smartsheet, and claims platforms.

• Able to manage multiple client deliverables while adhering to strict deadlines.

• Excellent written communication and documentation abilities.

• Skilled at keeping stakeholders informed without needing prompts.

🏝️ Benefits

• Bonus

• Equity

• Equal Opportunity Employer with an inclusive culture

• Rightway health guides and human experts available for members (this describes company product/service, not an employee benefit)