Clinical Operations Analyst

AffirmedRx is on a mission to improve health care outcomes by bringing clarity, integrity, and trust to pharmacy benefit management. We are committed to making pharmacy benefits easy to understand, straightforward to access and always in the best interest of employers and the lives they impact. We accomplish this by bringing total clarity to business practices, leading with clinical approaches, and utilizing state-of-the-art technology.

Join us in improving health care outcomes for all! We promise to do what's right, always.

Position Summary:

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.

What you will do:

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
  
  

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
  
  

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
  
  

Regulatory Compliance:

• Ensure clinical operations meet quality and compliance standards
  
  

What you need:

• 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%)
  
  

What you get:

• 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
  
  

Note:

AffirmedRx is committed to providing equal employment opportunities to all employees and applicants for employment. Remote employees are expected to maintain a professional work environment free of distractions to ensure optimal performance and collaboration.