Product Resolution Analyst

What you’ll do

In a few words…

Abarca is igniting a revolution in healthcare. We built our company on the belief that with smarter technology we are redefining pharmacy benefits, but this is just the beginning…

Our Product Team is the steady bridge between clients and tech teams at Abarca. They lead us towards #PBMAwesome by brainstorming new innovations, improvements and scaling for our product and technology offerings! Attention to detail and observational skills are key in this team to ensure our products are fully functional and maintain quality. Our Product Owners and Managers also ensure all program specifications are correct, business requirements are properly established, and operating procedures are adjusted as needed.

The Product Resolution Analyst you will assist as a liaison between client team members, software engineers, and product team. This involves conducting investigations into potential claim adjudication issues related to business processes and adjudication functionality (such as gap analysis, impact assessment, etc.). You will also collaborate with stakeholders to create potential solutions that integrate system functionality and business processes.

The fundamentals for the job…

• Develops in-depth understanding of Darwin adjudication system to ensure accurate investigation is performed.
• Conducts investigations of paid and rejected claims to determine potential issues within in the adjudication process according to drug pricing, configuration settings, benefit design, and claim edits.
• Interprets XML content relevant to the reported issues and creates queries to assist during the claim investigations.
• Identifies adjudication deficiencies during the investigation process and provides potential solutions towards new or enhanced functionality to improve product quality.
• Documents all relevant information that was performed or discussed off-line during the investigation process.
• Applies critical thinking skills and utilizes resources to ensure all investigations are performed with the highest level of quality to prevent rework.
• Collaborates with the Engineering team aimed on debugging, and produce client-appropriate Issue Summary, Root Cause Analysis, Corrective Actions, Preventative Measures, Impact Criteria, Impact Analysis Review and/or Coordination.
• Engages with business partners, product owners, and engineers to ensure a thorough understanding of the business processes.
• Participates in daily meetings to provide status updates, review priorities, coordinate tasks, and discuss troubleshooting strategies for investigations.
• Supports in the preparation for CMS, client or internal audits as well as follow through on any investigations.
• Maintains regular communication with the manager, promptly informing them of any issues or escalations.
• Achieve the performance goals and adhere to the established timelines for responsibilities.
• Performs additional tasks or special projects as assigned.

What we expect of you

The bold requirements…

• Bachelor’s Degree (In lieu of a degree, equivalent relevant work experience may be considered).
• 3+ years of relevant PBM and/or health plan operational experience, including experience in pharmacy and/or medical claims processing, benefit configuration, claim analyses, or related area.
• Strong analytical, planning, problem identification, and resolution skills, with self-initiative.
• Ability to independently troubleshoot claim functionality within the claim system or databases.
• Proficient time management abilities, evidenced by effectively managing multiple deliverables with varying deadlines.
• Experience in leveraging and utilizing SQL, business intelligence and associated data analysis tools.
• Experience utilizing dashboard tools, e.g., Tableau, QVW, and Excel tools.
• Ability to work independently as well as with team members for successful collaboration to achieve common or shared goals.
• Experience with Healthcare, Pharmacy, and Pharmacy Benefit industries, Medicare Part D, and CMS regulations, NCPDP standards and/or HIMSS.
• Excellent written and verbal communications, both formal and informal.
• We are proud to offer a flexible hybrid work model which will require certain on-site workdays (Puerto Rico Location Only)

Nice to haves…

• Experience with accumulator programs.
• Experience in PBM end-to-end claim testing.
• Experience with business intelligence solutions to create ad-hoc queries to support analysis.

Physical requirements…

• Must be able to access and navigate each department at the organization’s facilities.
• Sedentary work that primarily involves sitting/standing.

At Abarca we value and celebrate diversity. Diversity, equity, inclusion, and belonging are guiding principles of Abarca and ensure Abarca’s workforce reflects the communities it serves. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.

Abarca Health LLC is an equal employment opportunity employer and participates in E-Verify. “Applicant must be a United States’ citizen. Abarca Health LLC does not sponsor employment visas at this time”

The above description is not intended to limit the scope of the job or to exclude other duties not mentioned. It is not a final set of specifications for the position. It’s simply meant to give readers an idea of what the role entails.