Data-Driven Claims Operations Specialist

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

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.