Clinical Operations Analyst

20 hours ago

🐎 Kentucky – Remote

Although this job is listed in Kentucky, this company may be open to hiring remote in other states.

⏰ Full Time

🟢 Junior

🏥 Clinical Operations

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AffirmedRx, a Public Benefit Corporation

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AffirmedRx is a Public Benefit Corporation dedicated to transforming the pharmacy benefit management (PBM) industry. Focused on transparency, patient-centric care, and innovative solutions, AffirmedRx aims to overcome the complexities and opacity that traditionally plague the PBM sector. By empowering individuals and organizations, the company provides clarity and unwavering support in navigating pharmacy benefits. AffirmedRx stands for integrity and partnership, striving to offer a healthier and more informed pharmacy benefits experience while boldly tackling the rising costs of healthcare and pharmaceuticals.

PBM • Pharmacy Benefit Management • Healthcare Analytics • Healthcare • Pharmaceuticals

11 - 50 employees

⚕️ Healthcare Insurance

📋 Description

• The Clinical Operations Analyst is responsible for claims adjudication, ensuring accurate coding of clinical benefit designs and formularies. • This role plays a key part in maintaining regulatory compliance and requires strong attention to detail. • By supporting accurate claims processing, the analyst helps optimize operational efficiency and adherence to industry standards. • Submit and ensure appropriate coding updates in claims adjudication platform related to clinical benefit setup and both standard and custom formulary updates. • Assist with building annual formularies in adjudication platform. • Assist team with weekly Medispan drug database changes and impact on formulary and benefit setup. • Conduct pre-testing and post-testing of formulary and benefit changes to ensure accuracy and functionality before deployment. • Troubleshoot and resolve escalations related to clinical coding, benefit setups, and other operational issues. • Pull reports and manipulate data to help identify issue trends or outliers and implement appropriate corrections. • Assist with development and maintenance of department process documents. • Provide audit support related to appropriate claims processing and clinical benefit support. • Conduct testing for new client clinical benefits and formulary appropriateness. • Coordinate with cross-functional teams to deliver seamless and timely implementations. • Assist with intake and adjudication of new business clinical override files. • Ensure clinical operations meet quality and compliance standards.

🎯 Requirements

• Bachelor’s degree in a healthcare related field or Associates with relevant experience required • 1-3 years of managed care or PBM experience, preferred • Claims processing experience, preferred • Time management, organizational, and multi-taking skills • Knowledge of pharmacy benefit design, drug utilization management, and healthcare regulations • Strong attention to detail and accuracy in data management • Analytical thinking and problem-solving skills • Ability to work independently and collaboratively within a team • Familiarity with Medispan or First Data Bank terminology preferred • Proficiency in Microsoft Office Suite (Excel, Word, etc.) • Willingness to travel (10-15%)

🏖️ Benefits

• Competitive compensation, including health, dental, vision and other benefits