PBM Claims Adjudication Specialist

AffirmedRx is on a mission to improve health care outcomes by bringing clarity, integrity, and trust to pharmacy benefit management. We are committed to making pharmacy benefits easy to understand, straightforward to access and always in the best interest of employers and the lives they impact. We accomplish this by bringing total clarity to business practices, leading with clinical approaches, and utilizing state-of-the-art technology.

Join us in improving health care outcomes for all!  We promise to do what’s right, always.

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. Reporting to the Manager, Data Operations, this person develops new client eligibility files and accumulator files, builds coding automations to streamline file processing, and sets up and manages SFTP connections for secure client file transmission. Deep, hands-on PBM claims adjudication experience is required — this role exists because getting eligibility and accumulator data right requires someone who genuinely understands how claims adjudicate, not just how files are formatted. Experience working with the RxSense platform is a significant plus.

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 

Claims Adjudication Expertise & Application:

• Apply deep, hands-on PBM claims adjudication knowledge to inform file design, testing, and issue resolution 
• Serve as the team’s go-to expert on adjudication logic, NCPDP standards, and claims processing rules 
• Partner with the Business Analyst, ETL Developer/File Management Analyst, and other Data Operations team members on complex client issues requiring adjudication expertise 

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

Note: 

AffirmedRx is committed to providing equal employment opportunities to all employees and applicants for employment. Remote employees are expected to maintain a professional work environment free of distractions to ensure optimal performance and collaboration.