Data Analyst-Rx Claims & Pharmacy Domain
This a Full Remote job, the offer is available from: New Jersey (USA)
Company Description
Derex Technologies Inc 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 array of customized IT talent solutions designed to improve productivity and drive results to global clients throughout North 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, Healthcare, 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, step therapy, quantity limits, and formulary tiers
- Support PBM integrations and data exchanges (e.g., eligibility files, claims feeds, rebates, encounter data)
- Perform root-cause analysis on claims payment issues, rejects, and member/provider escalations
- Ensure claims logic aligns with CMS, state Medicaid, and commercial regulatory requirements
Data Analysis & Reporting
- Query and analyze large Rx claims datasets using SQL and analytical tools to identify trends, anomalies, and financial impacts
- Develop and maintain operational, financial, and compliance reports related 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 downstream 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 complex pharmacy and claims concepts clearly 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 healthcare 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, Medicaid pharmacy programs, and encounter/PDE reporting Regards, Manoj Derex Technologies INC Contact : 973-834-5005 Ext 206 Additional Information All your information will be kept confidential according to EEO guidelines. This offer from "Derex Technologies Inc" has been enriched by Jobgether.com and got a 72% flex score. Apply tot his job Apply To this Job