Assists in the set-up and maintenance of affordability programs and other ConnectiveRx adjudicated program offerings
Respond to and resolve business rule questions or concerns escalated by internal teams or adjudicator partners, escalating complex issues as appropriate
Conduct quality control reviews on new program setups and requested updates to ensure accuracy, consistency, and adherence to established rules and standards
Access, analyze, and interpret program and adjudication data to evaluate rule functionality; investigate discrepancies, anomalies, or incorrect outcomes and document findings
Develop and maintain a working knowledge of adjudication claims engines and networks, including differences in system logic across multiple adjudicators
Works proficiently within various tools (Salesforce, ManageEngine, CRx systems) to fulfill requests
Support documentation updates and process improvements
Primarily responsible for maintaining SOPs, work instructions, job aids, tracking logs and spreadsheets
Participate in regularly scheduled adjudication calls, ad hoc meetings, and internal discussions; engage in training sessions as required to support operational objectives

Bachelor’s degree from 4-year college or university or equivalent experience required
Minimum 2-4 yrs of pharmacy technician/adjudication experience
Prior experience performing quality checks, operational analysis, or investigative work preferred
Knowledge of healthcare operations claims processing, pharmaceutical affordability programs, or other rules-driven operational environments
Understanding of quality control methodologies, issue investigation, and root-cause analysis
Familiarity with interpreting, applying, and questioning documented business rules
Awareness of operational standards and documentation
Intermediate skill level in Microsoft office applications
Proficient analytical and problem-solving skills with the ability to conduct independent investigations
Excellent attention to detail and accuracy in data analysis, quality checks, and documentation
Proficient ability to listen actively and effective written and verbal communications skills for conveying findings, issues, and recommendations.

Analyst – Adjudication

Key skills