Position Summary:We are seeking a highly analytical Analyst to join our Analytics team and support pharmacy claims integrity, adjudication validation, and operational excellence. This role will use SQL and large-scale pharmacy claims data to investigate claim outcomes, identify discrepancies, validate benefit and pricing configurations, and ensure claims adjudicate accurately and in accordance with contractual and regulatory requirements.
The ideal candidate combines strong analytical and technical skills with a natural curiosity for understanding how pharmacy claims are processed. They will work closely with Finance, Legal, Product, Operations, Network, and other cross-functional stakeholders to investigate issues, quantify impacts, support audits, and drive process improvements. This individual will play a key role in protecting financial accuracy, mitigating risk, and ensuring a high-quality member and pharmacy experience.
Key Responsibilities: - Analyze and Validate Pharmacy Claims
- Use SQL and other analytical tools to review pharmacy claims data and validate adjudication outcomes.
- Investigate claim pricing, benefit application, reimbursement calculations, accumulators, and other claim-processing logic to identify discrepancies or errors.
- Perform root cause analyses on adjudication issues and partner with stakeholders to develop corrective actions.
- Develop repeatable monitoring and surveillance processes to identify anomalies, trends, and potential financial or operational risks.
- Partner Across Functional Teams
- Collaborate with Finance, Legal, Product, Operations, Network, and Compliance teams to interpret requirements and assess claim-processing outcomes.
- Support audits, regulatory reviews, contractual validations, and financial reconciliations through detailed claims analysis.
- Translate technical findings into clear, actionable recommendations for business stakeholders.
- Participate in cross-functional discussions to evaluate system changes, benefit implementations, and operational processes.
- Deliver High-Quality Analytics
- Develop and maintain SQL queries, reports, dashboards, and analytical tools that support claims oversight and operational decision-making.
- Ensure analyses are accurate, well-documented, reproducible, and supported by appropriate quality controls.
- Identify opportunities for automation and process improvement to increase efficiency and reduce risk.
- Support Risk Management and Compliance
- Help identify and quantify financial, operational, and compliance risks associated with claims processing.
- Validate that claims adjudicate in accordance with benefit designs, contractual requirements, and company policies.
- Maintain documentation of methodologies, business rules, findings, and remediation activities.
Qualifications & Experience: - 4-6 years of experience in healthcare analytics, pharmacy analytics, PBM operations, claims auditing, or a related field.
- Advanced SQL skills with the ability to analyze large, complex datasets.
- Experience performing pharmacy reimbursement, network pricing, financial reconciliation, contract compliance, or payment-integrity analysis.
- Ability to interpret complex contractual pricing terms and convert them into documented calculations, validation rules, and analytical test cases.
- Experience investigating discrepancies across claims, pricing reference data, contract terms, adjudication logic, and financial outputs.
- Demonstrated ability to quantify financial exposure and communicate material findings, assumptions, and limitations to Finance, Legal, Network, Product, and executive stakeholders.
Preferred Qualifications: - PBM industry experience
- Experience with pharmacy network contracting, reimbursement analysis, effective-rate reconciliation, or contract compliance
- Experience using drug reference and pharmacy reference data
- Familiarity with financial controls, audit support, accrual processes, recoveries, or materiality assessment
- Experience creating automated exception monitoring and reconciliation frameworks
New York, NY Salary Range
$132,795-$188,500 USD
Denver, CO Salary Range
$121,523-$172,500 USD
Charlotte, NC Salary Range
$110,604-$157,000 USD
All employees are responsible for adherence to the Judi Health Code of Conduct including the reporting of non-compliance. This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.
