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Clinical Operations Analyst
@AffirmedRx, PBC
[Hiring] Clinical Operations Analyst @AffirmedRx, PBC
Mar 13, 2025 - AffirmedRx, PBC is hiring a remote Clinical Operations Analyst. 💸 Salary: unspecified. 📍Location: USA.
This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more.
Role 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.
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Claims Adjudication:
- 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
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Testing, Quality Assurance, and Audit Support:
- 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
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Implementation 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
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Regulatory Compliance:
- Ensure clinical operations meet quality and compliance standards
Qualifications
- 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-tasking 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
- To impact industry change in the pharmacy benefits management space, while delivering the highest quality patient outcomes
- To work in a culture where people thrive because when OUR team thrives, OUR business thrives
- Competitive compensation, including health, dental, vision and other benefits
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| 📍 | Be aware of the location restriction for this remote position: USA |
| ‼ | Beware of scams! When applying for jobs, you should NEVER have to pay anything. Learn more. |
Back to Remote jobs >
All others
All others
|
Salary
💸
unspecified
|
Remote
Location
USA
|
|
Job Type
unspecified
|
Posted
Mar 13, 2025
|
️
| 📍 | Be aware of the location restriction for this remote position: USA |
| ‼ | Beware of scams! When applying for jobs, you should NEVER have to pay anything. Learn more. |
