Data Analyst Pharmacy Claims(Only on W2)

Role: Data Analyst Location: Remote. The candidate may be expected to travel to NJ office 1-2 times in a month. Must have experience on Rx claims and health insurance payer or PBM environment Rx Claims & Pharmacy Domain • Analyse end-to-end Rx claims adjudication workflows, including eligibility, benefit design, formulary, pricing, accumulators, edits, prior authorization, and reversals • Interpret and validate pharmacy benefit requirements such as copays, coinsurance, deductibles, OOP max, step therapy, quantity limits, and formulary tiers • Support PBM integrations and data exchanges (e.g., eligibility files, claims feeds, rebates, encounter data) • Perform root-cause analysis on claims payment issues, rejects, and member/provider escalations • Ensure claims logic aligns with CMS, state Medicaid, and commercial regulatory requirements Data Analysis & Reporting • Query and analyze large Rx claims datasets using SQL and analytical tools to identify trends, anomalies, and financial impacts • Develop and maintain operational, financial, and compliance reports related to pharmacy utilization, spend, and claims accuracy • Support audits, reconciliations, and compliance reporting (e.g., CMS encounters, PDEs, state reporting) • Validate data accuracy across upstream and downstream systems Systems & Business Analysis • Gather and document business requirements and translate them into functional specifications, data mappings, and system rules • Partner with IT and vendors to support system enhancements, benefit changes, releases, and production issue resolution • Participate in UAT planning and execution, including test case creation, test data validation, and defect triage • Support modernization initiatives, including claims platform upgrades, PBM transitions, and data integrations Cross-Functional Collaboration • Act as a liaison between Pharmacy Operations, IT, Finance, Compliance, and vendors • Communicate complex pharmacy and claims concepts clearly to technical and non-technical stakeholders Required Qualifications • 5+ years of experience as a Data Analyst, Systems Analyst, or Business Analyst in a health insurance payer or PBM environment • Strong hands-on experience with Rx claims data and pharmacy benefit management • Advanced proficiency in SQL and experience working with large healthcare datasets • Solid understanding of pharmacy benefit design, claims adjudication logic, and payer operations • Experience supporting production issues, audits, and regulatory reporting • Excellent communication skills with the ability to work across technical and business teams Preferred Qualifications • Experience with Rx claims platforms (e.g., Facets Rx, QNXT, RxClaim, MedImpact, Caremark, OptumRx) Familiarity with CMS Part D, Medicaid pharmacy programs, and encounter/PDE reporting Apply To this Job Company : Resource Innovative Technologies LLC Salary : Work from home