Pharmacy Benefits Claims Consultant

Acrisure; Cadillac (MI); On-site; USD 65,000 - 90,000; Full time

Job summary

Acrisure is seeking a Claims Consultant to support the administration and processing of pharmacy benefit claims for self-funded employer health plans. The role acts as a key liaison among clients, plan members, pharmacies, PBMs, TPAs, carriers, brokers, and internal teams to ensure claims are processed accurately and efficiently.

You will analyze claim issues, resolve discrepancies, identify cost-saving opportunities, and provide education on claim processes and benefits.

Qualifications

• Minimum 3 years in health insurance, pharmacy benefits, or claims administration.
• Experience with self-funded health plans, PBMs, or TPAs preferred.
• Bilingual English/Spanish is preferred to support diverse members.

Responsibilities

• Review, investigate, and resolve pharmacy benefit claim issues promptly.
• Analyze adjudication outcomes and identify discrepancies.
• Coordinate with pharmacies, PBMs, TPAs, and brokers to resolve complex claims.
• Research eligibility, benefit design, and prior authorization to determine outcomes.
• Monitor payment accuracy and regulatory compliance.
• Assist in auditing and reconciliation of pharmacy claims data.
• Support client implementation projects and plan changes.
• Maintain documentation of investigations, resolutions, and communications.
• Partner with Account Management and Operations to ensure seamless service.
• Provide education on claim processes and cost-management strategies.
• Stay current on pharmacy benefit trends and healthcare regulations.

Skills

Healthcare claims knowledge

Analytical skills

Customer service

Communication skills

Bilingual English/Spanish

Education

Bachelor's degree in business, Healthcare Administration, Finance, Insurance, Public Health, or related field

Tools

Excel

Claims adjudication systems

Reporting platforms

Microsoft Office Suite

Job description

Acrisure is seeking a Claims Consultant to support the administration and processing of pharmacy benefit claims for self-funded employer health plans. The role acts as a key liaison among clients, plan members, pharmacies, PBMs, TPAs, carriers, brokers, and internal teams to ensure claims are processed accurately and efficiently.

You will analyze claim issues, resolve discrepancies, identify cost-saving opportunities, and provide education on claim processes and benefits.