Claims Operations Analyst

EmpiRx Health; Montvale (NJ); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Medical insurance

Prescription coverage

Vision & dental

Life & disability

401K program

Parental leave

Student loan reimbursement

Flexible PTO

Hybrid/Remote options

Job summary

EmpiRx Health is seeking a Claims Operations Specialist to manage benefit and claims issues, monitor trends, and process manual claims for member reimbursement and subrogation requests. You will ensure data integrity and high member satisfaction through collaboration with internal and external stakeholders.

The role emphasizes operational efficiency, documentation, and proactive problem resolution, with on-site work in Orlando, FL. A Bachelor’s degree and 1–2 years PBM experience are preferred.

Qualifications

• 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.

Responsibilities

• Investigate and resolve complex claim, eligibility, and accumulator issues within service level agreements, ensuring issues are researched and documented according to departmental/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, & 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.

Skills

Attention to detail

Organizational skills

Analytical skills

Written and verbal communication

Problem solving

Education

Bachelor’s degree or equivalent experience

Tools

SQL

Excel

Job description

Claims Operations Specialist

EmpiRx Health is the leading clinically-driven pharmacy benefits management company. As the pioneer in value-based pharmacy care, EmpiRx Health puts its customers and members first by enabling them to take control of their pharmacy benefits, healthcare outcomes, and financial results.

We place more emphasis on member care than any other PBM by focusing on health outcomes first. Our pharmacists and clinicians are at the center of everything we do- and our population health solution delivers tailored strategies for our clients. Leveraging our newly launched, AI-powered pharmacy care platform, Clinically , EmpiRx Health’s pharmacists and client experience teams provide the highest quality pharmacy care to our clients and their members. This enables benefits plan sponsors to keep their members healthy, happy, and productive, while substantially reducing prescription drug spending, which has been on an explosive growth trajectory in recent years.

EmpiRx Health is experiencing a period of accelerated growth and platform expansion. We’re seeking a Claims Operations Specialist. 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.

Key Responsibilities

• Investigate and resolve complex claim, eligibility, and accumulator issues within service level agreements, ensuring issues are researched and documented according to departmental & 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, & 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.

Required Qualifications & Experience

• 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 And Perks

Our commitment to diversity is reflected in our family and LGBTQ-friendly benefits, which include:

• Comprehensive medical, prescription, vision, dental, life, and disability insurance, with coverage for domestic partnerships.
• A 401K program to secure your financial future.
• Parental leave for childbirth and adoption.
• Student loan reimbursement.
• Additional perks include flexible PTO, hybrid and remote work arrangements, online wellness resources and counseling access.

EmpiRx Health is an Equal Opportunity Employer

At EmpiRx Health, we wholeheartedly embrace the power of diversity and the magic of inclusion. The kaleidoscope of unique perspectives, backgrounds, and talents fuels our innovation and sets us apart. We're on a mission to build a team as diverse as the world we