PBM Claims Adjudication Specialist

Position Summary

The PBM Claims Adjudication Specialist is a deeply technical, hands-on role responsible for building and maintaining client eligibility and accumulator files that ensure AffirmedRx's data is always comprehensive, always accurate.

What you will do

• Client Eligibility File Development: Design, build, and configure new client eligibility files based on client-specific requirements and benefit plan designs. Translate client eligibility rules and benefit structures into accurate file specifications and processing logic. Test and validate eligibility files prior to go-live to confirm accuracy before they reach production.
• Accumulator File Development & Management: Design, build, and maintain accumulator files reflecting member deductible, out-of-pocket, and benefit accumulator data. Ensure accumulator logic aligns correctly with plan design and claims adjudication rules. Investigate and resolve discrepancies in accumulator data before they affect members or clients.
• Coding Automation: Develop automations and scripts that streamline file build, testing, and validation processes. Reduce manual, repetitive work across eligibility and accumulator file processing through coding and automation. Maintain and continuously improve existing automations as client needs and file formats evolve.
• SFTP Setup & Management: Configure and manage SFTP connections for new and existing client file transmissions. Ensure secure, reliable file transfer setup for all client eligibility and accumulator data exchanges. Troubleshoot SFTP connectivity and transmission issues, escalating and resolving quickly to avoid data gaps.
• Data Accuracy & Ongoing Maintenance: Ensure eligibility and accumulator data remains comprehensive and always accurate across all clients. Proactively identify and resolve data discrepancies before they surface as client- or member-facing issues. Support the change control process for any changes to client files, layouts, or related production systems.

What you need

• Bachelor's degree in a related field, or equivalent experience
• Required: deep, hands-on experience with PBM claims adjudication, including how claims process, adjudicate, and interact with eligibility and accumulator data
• 7+ years of direct PBM experience building and maintaining client eligibility files and accumulator files
• Experience working with the RxSense platform is a significant plus
• Strong knowledge of NCPDP standards, claims processing rules, and benefit design as they relate to file build and testing
• Experience with SFTP setup, configuration, and management for secure client file transmission
• Excellent troubleshooting and problem-solving skills, with the judgment to catch data issues before they become client- or member-facing problems
• High attention to detail, given the accuracy-critical nature of eligibility and accumulator data
• Comfortable working both independently and as part of a small, collaborative team
• Mission-driven, humble, and supportive; holds high standards while fostering learning rather than blame
• Aligns with AffirmedRx values, promoting trust, accountability, and innovation
• Willingness to travel (10%-20%)

What you get

• To impact industry change in the pharmacy benefits management space, while delivering the highest quality patient outcomes
• To work in a culture where people thrive because when OUR team thrives, OUR business thrives
• Competitive compensation, including health, dental, vision and other benefits