Claims Reprocessing Analyst

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 client 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 MTM, price eligibility, configurations, and beneficiary services to government services and beyond. The Darwin Claims Operations team handles all claims verifications, day to day configuration set-up and maintenance as well as related special projects, issue management and research for configuration.

As our Claims Reprocessing Analyst, you will be responsible for the completion of all reprocessing tasks and claims adjustments accurately and based on established SLAs. These include claims reprocessing and adjustments for all lines of business, as well as supporting with documentation and training other staff members. Part of the job is cross functional collaboration to ensure tasks are completed timely and towards client satisfaction.

The fundamentals of the job…                                              

• Conduct claim reprocessing and adjustments, including approvals, related to claim adjudication errors, configuration changes and operational requests including any restacking for Medicare clients. Ensure a proper and timely resolution.
• Conduct detailed quality reviews of claim data to ensure accuracy of all work.
• Collaborate with other internal teams to analyze claim reprocessing efficiency, prompt resolution of requests and results to reduce errors.
• Monitor, track, and communicate client ready updates for all assigned tickets and tasks.
• Ensure all client requests in compliance with the SLAs and communicate risks to timeline adherence.
• Participate, as requested, in client meetings and internal calls to provide updates regarding all assigned tickets and tasks.
• Be an SME or claims reprocessing and collaborate in the development of policies and procedures. Training the Team as needed to new policies and changes.
• While conducting all activities, take the initiative identifying and proactively suggesting any opportunities and/or risks.
• Support the documentation of business requirements for the Claims Reprocessing, Payments Adjustments modules.
• Conduct testing for enhancements and fixes related to Reprocessing and Adjustments modules.
• Run SQL queries, request reports from Analytics, and use data to make decisions.

What we expect of you: 

The bold requirements…

• Bachelor or master’s degree in Business, Audit, Insurance, Healthcare, or related field. (In lieu of a degree, equivalent relevant work experience may be considered.)
• 5+ years of experience in an analytical, claims processing, benefit configuration or QA/ auditing role in healthcare or PBM.
• Experience in PBM and Medicare/Medicaid.
• Excellent oral and written communications skills.

Nice to have…

• Bilingual fluency in English & Spanish.

That something extra we´d love to see…

1. Analytical
2. Team player
3. Driven
4. Negotiator

Physical requirements…

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

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.

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

All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of gender, race/ethnicity, gender identity, sexual orientation, protected veteran status, disability, or other protected group status.

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