Claims Operations Analyst

About the role

EmpiRx Health is the leading clinically-driven pharmacy benefits management company. As the pioneer in value-based pharmacy care, we put our customers and members first by enabling them to take control of their pharmacy benefits, healthcare outcomes, and financial results. Our pharmacists and clinicians are at the center of everything we do, delivering tailored population health solutions and the highest quality pharmacy care through our AI-powered platform, Clinically™.

The Claims Operations Specialist is responsible for managing benefit and claims issues, monitoring claims trends, and processing manual claims for direct member reimbursement and subrogation requests. This role ensures operational efficiency, data integrity, and member satisfaction by identifying trends, resolving issues, and collaborating with internal and external stakeholders to enhance claims processes.

Responsibilities

• Investigate and resolve complex claim, eligibility, and accumulator issues within service level agreements, ensuring issues are researched and documented according to departmental and enterprise standards.
• Conduct adaptable root cause analysis to identify short-term and long-term fixes and improvements to specific or systemic problems.
• Partner with technology, client services, customer service, finance, and privacy/legal/compliance teams to improve solution design and overall operational effectiveness.
• Monitor claims data on an ongoing basis to identify adverse or actionable trends related to claim issues, including errors with eligibility and accumulator integration.
• Execute the processing of direct member reimbursement requests.
• Coordinate with relevant departments to address and process subrogation claims effectively.
• Maintain detailed records of all manual claims processed.
• Proactive ownership of documentation materials related to benefit plan design while ensuring accuracy and accessibility for customers and stakeholders.

Requirements

• 1–2 years of experience in pharmacy benefit administration, operations, or related areas.
• Strong attention to detail, organizational skills, and ability to manage multiple priorities.
• Bachelor’s degree or equivalent experience.
• Demonstrated experience in issue management and problem resolution.
• Strong analytical skills with ability to interpret data, identify trends/outliers, and diagnose potential issues.
• Prior experience with eligibility and accumulator data.
• Prior experience with claims adjudication platforms.
• Familiarity with direct reimbursement processes and related systems.
• Excellent written and verbal communication skills, with a focus on member and client satisfaction.

Preferred Qualifications

• Technical proficiency and aptitude.
• Proficiency in Microsoft Office Suite, primarily Excel.
• Experience using SQL to perform data investigation and solution design.
• Experience with change control methodologies to aid issue resolution.
• Experience with personalized medicine or precision-based solutions.
• Understanding of payer, provider, or employer market dynamics.
• Experience designing solutions for whole-person care or population health strategies.
• Familiarity with AI/ML innovations and human-centered application in healthcare.

Work Environment

Fully on-site in Orlando, FL (5 days per week).

Benefits

• Comprehensive medical, prescription, vision, dental, life, and disability insurance, with coverage for domestic partnerships.
• 401K program.
• Parental leave for childbirth and adoption.
• Student loan reimbursement.
• Flexible PTO.
• Hybrid and remote work arrangements.
• Online wellness resources and counseling access.