PBM Claims Analyst - Guaynabo PR

Location: Guaynabo, PR 

PBM Claims Analyst is responsible for auditing, analyzing, and tracking accounts receivable related to Pharmacy Benefit Managers (PBMs) at a specialty pharmacy. This role focuses primarily on reviewing and validating payments, identifying discrepancies, and analyzing unpaid payments. The analyst’s primary responsibility is to audit, document, and report findings to the teams. 

Responsibilities: 

• Conduct daily audits of PBM-related accounts receivable to identify outstanding balances.
• Analyze claims that have been paid, partially paid, or unpaid, as processed in “View Response.”
• Review PBM remittances, reports, and electronic files to verify the accuracy of payments.
• Identify discrepancies between amounts billed, amounts paid, and contractually expected amounts.
• Clearly and thoroughly document audit findings in the established systems.
• Refer cases of errors, partial payments, or required adjustments to the Operations team.
• Follow up on referred cases until resolution, without performing reprocessing.
• Prepare lists and reports of audited and referred PBM accounts and discuss them with your Supervisor.
• Identify recurring patterns of errors, delays, or non-compliance by PBMs.
• Communicate financial trends and risks to the appropriate Supervisor or Manager.
• Support internal and external audits related to PBM accounts receivable.

Requirements: 

• Associate's degree in Medical Billing and Coding, Health Services Administration, Medical Office Administration, Medical Records, or related fields in the healthcare sector.

***Equal Opportunity Employer M/F/V/D**