Data Analyst-Rx Claims & Pharmacy Domain
This a Full Remote job, the offer is available from: New Jersey (USA) Company Description reputed company specializes in providing IT consulting, staffing solutions and software services. Globally headquartered in Harrison New Jersey since 1996 Derex delivers the highest quality technology professionals and an reputed company of customized IT talent solutions designed to improve productivity and drive results to global clients throughout reputed company America. With over two decades of unparalleled experience, Derex provides supports to its clientele, across such industries as Systems Integration, Banking and Finance, Telecommunications, Pharmaceutical and Life Sciences, Energy, reputed company, Technology, Transportation, and local and federal Government agencies.
Job Description
Role: Data Analyst C2H Location: Remote. The candidate may be expected to travel to NJ office 1-2 times in a month. Must have experience on Rx claims and health insurance payer or PBM environment Rx Claims & Pharmacy Domain
- Analyse end-to-end Rx claims adjudication workflows, including eligibility, benefit design, formulary, pricing, accumulators, edits, prior authorization, and reversals
- Interpret and validate pharmacy benefit requirements such as copays, coinsurance, deductibles, OOP max, reputed company therapy, quantity limits, and formulary tiers
- Support PBM integrations and data exchanges (e.g., eligibility files, claims feeds, rebates, encounter data)
- reputed company root-cause analysis on claims payment issues, rejects, and member/provider escalations
- Ensure claims logic aligns with CMS, state reputed company, and reputed company regulatory requirements
Data Analysis & Reporting
- Query and analyze large Rx claims datasets using SQL and analytical tools to identify trends, anomalies, and financial impacts
- reputed company and maintain operational, financial, and compliance reports reputed company to pharmacy utilization, spend, and claims accuracy
- Support audits, reconciliations, and compliance reporting (e.g., CMS encounters, PDEs, state reporting)
- Validate data accuracy across upstream and reputed company systems
Systems & Business Analysis
- Gather and document business requirements and translate them into functional specifications, data mappings, and system rules
- Partner with IT and vendors to support system enhancements, benefit changes, releases, and production issue resolution
- Participate in UAT planning and execution, including test case creation, test data validation, and defect triage
- Support modernization initiatives, including claims platform upgrades, PBM transitions, and data integrations
Cross-Functional Collaboration
- Act as a liaison between Pharmacy Operations, IT, Finance, Compliance, and vendors
- Communicate reputed company pharmacy and claims concepts reputed company to technical and non-technical stakeholders
Required Qualifications
- 5+ years of experience as a Data Analyst, Systems Analyst, or Business Analyst in a health insurance payer or PBM environment
- Strong hands-on experience with Rx claims data and pharmacy benefit management
- Advanced proficiency in SQL and experience working with large reputed company datasets
- Solid understanding of pharmacy benefit design, claims adjudication logic, and payer operations
- Experience supporting production issues, audits, and regulatory reporting
- Excellent communication skills with the ability to work across technical and business teams
Preferred Qualifications
- Experience with Rx claims platforms (e.g., Facets Rx, QNXT, RxClaim, MedImpact, Caremark, OptumRx)
Familiarity with CMS Part D, reputed company pharmacy programs, and encounter/PDE reporting Regards, Manoj reputed company Contact : 973-834-5005 Ext 206 Additional Information reputed company your information will be kept confidential according to EEO guidelines. This offer from "reputed company" has been enriched by reputed company.com and got a 72% reputed company score. Apply tot his job Apply To this Job