What you’ll do

In a few words… 

Abarca is igniting a revolution in healthcare.  We built our company on the belief that with smarter technology we are redefining pharmacy benefits, but this is just the beginning… 

Providing high quality services to clients and beneficiaries is at the core of what we do every day! The PBM Operations & Services team is the very heart of Abarca and meets that standard by running services from day-to-day configurations set-up and maintenance, case verifications, beneficiary services and beyond. In the Pharmacy Claims Services team, we manage all manual claims and are responsible for claim reprocessing and adjustments.  

As Associate Claims Processing Analyst, you’ll be responsible for the timely and accurate processing of prescription claims.  Claims Processing includes within its scope the operational services for Direct Member Reimbursements, Manual Pharmacy Claims, and Subrogation for all lines of business including Commercial, Medicare and Medicaid.  You will manage assigned cases ensuring compliance with established policies and procedures as well as regulatory and contractual requirements. 

 

The fundamentals for the job… 

•  Accurately enter prescription claims information into the system, ensuring data integrity and compliance with company policies and regulations. 
• Complete all tasks related to PBM Claim Services for members, pharmacies and payers per established process and in accordance with contract requirements and applicable regulations.
• Conduct detailed quality reviews of claims processing results to ensure accuracy of all work.
• Collaborate with team members and other departments to analyze claim processing accuracy, reduce errors and ensure prompt resolution of requests.
• Identify and resolve discrepancies or issues in prescription claims, working collaboratively with internal and external stakeholders.
• Engage in proactive outreach to pharmacies, prescribers, or patients to verify and obtain missing information, ensuring the successful adjudication of claims.
• Provide exceptional customer service by addressing inquiries and resolving issues related to prescription claims in a timely and professional manner.   
• Monitor, track, and communicate client ready updates for all assigned cases, tickets and tasks.  
• Ensure all client requests are managed according to established SLOs/ SLAs and communicate to the Claims Services Supervisor  and/or Manager any risks in a timely manner. 
• Participate, as requested, in internal calls and client meetings to provide updates and explanations regarding assigned claims processing tickets and tasks with support from Supervisor and/or Manager.
• Run and/or request reports from Analytics, and use data to analyze claims and make decisions.
• Participate in training and development opportunities to continuously enhance knowledge and skills relevant to claims processing. 

 

 What we expect of you 

The bold requirements…  

• Associate’s Degree in Pharmacy Technician, Business, Audit, Insurance, Healthcare, or related field. (In lieu of a degree, equivalent relevant work experience may be considered.) 
• 1+ years of experience in analytical, claims processing, benefit configuration, quality assurance or auditing role in healthcare.
• Excellent analytical and problem-solving skills.  
• Ability to establish good interpersonal skills.  
• Excellent oral and written communication skills in English and Spanish.
• We are proud to offer a flexible hybrid work model which will require certain on-site workdays (Puerto Rico Location Only).
• This position requires availability for on-call hours, including evenings, weekends, and holidays, to promptly address emergent issues or provide necessary support as dictated by operational demands (if applicable).
• This position requires availability to work in a specified time zone, accommodating the business needs of our clients and team members based in the determined time zone.

 

Nice to haves…

• Prior experience in pharmacy benefit management.
• Experience related to Medicare and Medicaid.

Physical requirements…

• Must be able to access and navigate each department at the organization’s facilities.
• Sedentary work that primarily involves sitting/standing.

 

At Abarca we value and celebrate diversity. Diversity, equity, inclusion, and belonging are guiding principles of Abarca and ensure Abarca’s workforce reflects the communities it serves.  We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.

Abarca Health LLC is an equal employment opportunity employer and participates in E-Verify.  “Applicant must be a United States’ citizen or Permanent Resident. Abarca Health LLC does not sponsor employment visas at this time”

The above description is not intended to limit the scope of the job or to exclude other duties not mentioned. It is not a final set of specifications for the position. It’s simply meant to give readers an idea of what the role entails.

 

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