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Pbm Claims Analyst Jobs (NOW HIRING)

Alivia Health

PR · On-site

Guaynabo, PR PBM Claims Analyst is responsible for auditing, analyzing, and tracking accounts receivable related to Pharmacy Benefit Managers (PBMs) at a specialty pharmacy. This role focuses ...

Alivia Health

PR · On-site

Guaynabo, PR El Analista de Auditoría PBM es responsable de auditar, analizar y dar seguimiento a las cuentas por cobrar relacionadas con Pharmacy Benefit Managers (PBM) en una farmacia ...

STI

Business Analyst (Healthcare PBM) - Remote

Seeking a Business Analyst with Healthcare/PBM experience to support pharmacy claims implementations through requirements gathering, data analysis, system integration, and testing. Responsibilities

Lucyrx

Financial Analyst

Bethesda, MD · On-site +1

Bachelor's in Finance, Accounting, Economics, Business, or related field. * 3-5+ years' experience in Finance/FP&A, PBM analytics, or contract/claims analytics. * Strong Excel skills (advanced ...

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Pbm Claims Analyst information

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How much do pbm claims analyst jobs pay per hour?

As of Jul 23, 2026, the average hourly pay for pbm claims analyst in the United States is $27.39, according to ZipRecruiter salary data. Most workers in this role earn between $20.19 and $31.49 per hour, depending on experience, location, and employer.

What is the difference between Pbm Claims Analyst vs Pharmacy Claims Processor?

AspectPbm Claims AnalystPharmacy Claims Processor
CredentialsRelevant certifications (e.g., CPC, CPhT), healthcare knowledgeBasic pharmacy technician certification, on-the-job training
Work EnvironmentHealthcare or insurance company offices, call centersPharmacy settings, mail-order pharmacies, retail pharmacies
Employer & IndustryPBMs, health insurance companies, healthcare providersPharmacies, retail chains, mail-order pharmacies
Job FocusClaims analysis, benefit management, data reviewProcessing pharmacy claims, data entry, verifying prescriptions

The main difference is that a Pbm Claims Analyst focuses on analyzing pharmacy benefit claims, managing data, and ensuring benefit accuracy, often requiring healthcare certifications. In contrast, a Pharmacy Claims Processor primarily handles the day-to-day processing of pharmacy claims, with less emphasis on analysis or benefit management.

What are some typical challenges faced by a PBM Claims Analyst and how can they be managed?

PBM Claims Analysts often face challenges such as navigating complex pharmacy benefit structures, managing large volumes of claims data, and keeping up with frequent changes in healthcare regulations. Staying detail-oriented and developing strong analytical skills are key to accurately processing claims and identifying discrepancies. Collaborating closely with pharmacists, providers, and other team members helps resolve issues efficiently, while ongoing training ensures analysts remain current with industry standards and compliance requirements.

What are the key skills and qualifications needed to thrive as a PBM Claims Analyst, and why are they important?

To thrive as a PBM Claims Analyst, you need strong analytical abilities, attention to detail, and knowledge of pharmacy benefit management and healthcare claims processes, typically supported by a degree in healthcare, business, or a related field. Familiarity with claims processing systems, pharmacy benefit management software, and proficiency in tools like Excel are commonly required, along with understanding HIPAA regulations. Excellent problem-solving, communication, and organizational skills help in resolving claim discrepancies and collaborating across teams. These competencies are vital for ensuring accurate claims adjudication, maintaining compliance, and supporting the financial integrity of pharmacy benefit programs.

What are PBM Claims Analysts?

PBM Claims Analysts are professionals who review, process, and resolve pharmacy benefit management (PBM) claims. They ensure that prescription drug claims are accurate, comply with insurance policies, and adhere to regulatory guidelines. These analysts often work for health insurers, PBMs, or healthcare organizations, handling claim discrepancies, reconciling payments, and answering questions from pharmacies or patients. Their role is crucial in ensuring that patients receive appropriate prescription benefits and that all transactions are processed efficiently.
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Pbm Claims Analyst jobs near you
Infographic showing various Pbm Claims Analyst job openings in the United States as of July 2026, with employment types broken down into 89% Full Time, 6% Part Time, 1% Temporary, and 4% Contract. Highlights an 83% Physical, 7% Hybrid, and 10% Remote job distribution, with an average salary of $56,974 per year, or $27.4 per hour.

PBM Claims Analyst - Guaynabo PR

Alivia Health

PR • On-site

Full-time

Posted 12 days ago

Job description

Location: Guaynabo, PR

PBM Claims Analyst is responsible for auditing, analyzing, and tracking accounts receivable related to Pharmacy Benefit Managers (PBMs) at a specialty pharmacy. This role focuses primarily on reviewing and validating payments, identifying discrepancies, and analyzing unpaid payments. The analyst’s primary responsibility is to audit, document, and report findings to the teams.


Responsibilities:

  • Conduct daily audits of PBM-related accounts receivable to identify outstanding balances.
  • Analyze claims that have been paid, partially paid, or unpaid, as processed in “View Response.”
  • Review PBM remittances, reports, and electronic files to verify the accuracy of payments.
  • Identify discrepancies between amounts billed, amounts paid, and contractually expected amounts.
  • Clearly and thoroughly document audit findings in the established systems.
  • Refer cases of errors, partial payments, or required adjustments to the Operations team.
  • Follow up on referred cases until resolution, without performing reprocessing.
  • Prepare lists and reports of audited and referred PBM accounts and discuss them with your Supervisor.
  • Identify recurring patterns of errors, delays, or non-compliance by PBMs.
  • Communicate financial trends and risks to the appropriate Supervisor or Manager.
  • Support internal and external audits related to PBM accounts receivable.


Requirements:

  • Associate's degree in Medical Billing and Coding, Health Services Administration, Medical Office Administration, Medical Records, or related fields in the healthcare sector.


***Equal Opportunity Employer M/F/V/D**