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Pbm Claims Analyst Jobs (NOW HIRING)

Forhyre

We are looking for a Claims Business Analyst who will be the vital link between our information ... Experience working within the Payer / PBM market (in particular Medicare and Medicaid, Part D and ...

Hilbgroup

Stop Loss Analyst

Canton, MA · Hybrid

$72K/yr

Download and review relevant reports from carrier, TPA, PBM, and stop loss carrier portals ... Manage and maintain monthly claims dashboards for assigned clients. * Review high-cost claimant ...

Hilb Group

Stop Loss Analyst

Canton, MA · On-site

$72K/yr

Download and review relevant reports from carrier, TPA, PBM, and stop loss carrier portals ... Manage and maintain monthly claims dashboards for assigned clients. * Review high-cost claimant ...

CEB Cranston EB

Stop Loss Analyst

Canton, MA · On-site

$65 - $79/hr

Download and review relevant reports from carrier, TPA, PBM, and stop loss carrier portals ... Manage and maintain monthly claims dashboards for assigned clients. * Review high-cost claimant ...

New

Hilbgroup

Stop Loss Analyst

Cranston, RI · Hybrid

$72K/yr

Download and review relevant reports from carrier, TPA, PBM, and stop loss carrier portals ... Manage and maintain monthly claims dashboards for assigned clients. * Review high-cost claimant ...

The Hilb Group

Stop Loss Analyst

Canton, MA · On-site

$65 - $79/hr

Download and review relevant reports from carrier, TPA, PBM, and stop loss carrier portals.Analyze ... Follow up persistently on pended or denied claims to ensure claims are adjudicated and reimbursed ...

New

Msmc

Office Coordinator Medicare Part D

Hialeah, FL

$16.25 - $21.75/hr

Assists with all Part D activities including: annual bid, Fraud Waste and Abuse Plan, PBM claims ... collecting, analyzing and reporting identifying measures. Schedules, attends and presents ...

Capital Rx

Account Coordinator, PBM

Manhattan, NY · On-site

$69K - $86K/yr

Judi Health replaces fragmented, outdated systems with the industry's first Unified Claims ... Analyze incoming client requests and work with internal and external teams to complete required ...

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Pbm Claims Analyst information

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How much do pbm claims analyst jobs pay per hour?

As of Sep 5, 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 a PBM Claims analyst?

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.

What are the key skills and qualifications needed to thrive as a PBM Claims analyst?

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 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 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.

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Pbm Claims Analyst jobs near you
Infographic showing various Pbm Claims Analyst job openings in the United States as of August 2026, with employment types broken down into 89% Full Time, 6% Part Time, and 5% Contract. Highlights an 82% Physical, 7% Hybrid, and 11% Remote job distribution, with an average salary of $56,974 per year, or $27.4 per hour.

Data Exchange Manager - Claims Operations

Capital Rx

Manhattan, NY • On-site

$150K - $188K/yr

Other

Medical, Dental, Vision

This job post has expired 1 day ago. Applications are no longer accepted.

Job description

About Judi Health

Judi Health is a health technology company providing benefit administration solutions to employers, unions, health plans, and government entities. Judi Health replaces fragmented, outdated systems with the industry's first Unified Claims Processing architecture, seamlessly consolidating pharmacy and medical benefit administration on a single, secure platform. By delivering true price transparency, eliminating unnecessary middleman fees, and leveraging advanced AI-powered care delivery, Judi Health helps clients achieve unprecedented operational efficiency and service levels.
At Judi Health, we're deploying the infrastructure our country needs to deliver the healthcare we all deserve. We are the intelligence platform powering benefits plans for millions of Americans and proudly leading the next generation of care. To learn more, visit www.judi.health.

Location: Hybrid 3 days (offices in NYC, Denver, CO and Charlotte, NC area)

Position Summary:

The Data Exchange Manager is responsible for leading day-to-day Data Exchange operations supporting both PBM and TPA (Medical, Dental and Vision) business lines. The role oversees analysts and specialists responsible for healthcare data integrations, client onboarding, EDI transactions, eligibility feeds, claims exchanges, configuration setup, data quality monitoring, and operational issue resolution.

Manager will works closely with internal teams and external partners to design, maintain, and troubleshoot data exchange processes that support claims, formulary, network, and eligibility operations. Success in this role requires deep PBM and TPA data expertise, strong analytical and problemsolving abilities, and the communication skills needed to drive alignment across JUDI Health and with our clients.

Position Responsibilities:

Data Feed & Integration Management

  • Lead and develop Data Exchange staff across PBM and TPA operations.Oversee connectivity setup and configuration activities for all new and existing clients.
  • Oversee healthcare data exchange operations, connectivity, onboarding and production support.
  • Manage PBM integrations including eligibility, claims, accumulator, formulary and network data.
  • Oversee TPA EDI transactions including 834, 837, 835, 270/271, 276/277 and 278.
  • Ensure data quality, reconciliation, audits and issue resolution.
  • Partner with Implementations, Client Services, Product, Engineering and external trading partners.
  • Drive automation, process improvement and operational excellence.
  • Ensure HIPAA and regulatory compliance.

Issue Resolution & Operational Excellence

  • Serve as a central coordination point for issue identification, triage, and resolution across internal teams and external integration partners.
  • Monitor system status, data movement, and platform dashboards to proactively detect abnormalities impacting quality or performance.
  • Ensure all data exchange issues are remediated according to established SLAs, operating standards, and audit controls.
  • Perform and oversee audits and reconciliation processes to validate data integrity across systems.

CrossFunctional & External Collaboration

  • Partner with Implementation, Operations, Client Success, Product, and Engineering to support client onboarding, migrations, vendor changes, and enhancement requests.
  • Act as a liaison across business areas to ensure alignment, clear communication, and coordinated prioritization.
  • Translate business requests into technical requirements, assess complexity, and support accurate effort estimation and SLA assignment.

Process Improvement & Documentation

  • Identify opportunities to streamline workflows, enhance data quality, and reduce operational risk through automation and process refinements.
  • Develop and maintain comprehensive documentation-including policies, procedures, and configuration standards for JUDI system operations.

Compliance & Regulatory Awareness

  • Stay current with Medicare, Medicaid, and state regulatory requirements to ensure all data exchange processes remain compliant.
  • Follow and reinforce the JUDI Health Code of Conduct, including escalation and reporting of noncompliance when appropriate.

Required Qualifications:

  • Bachelor's degree or equivalent experience.
  • 5+ years in healthcare data exchange, EDI, PBM or claims administration.
  • Leadership experience within a PBM or healthcare setting, preferably managing highvolume data exchange or interoperability functions.
  • Knowledge of PBM and TPA data structures and healthcare EDI standards.
  • Proficiency in SQL, Excel, and other analytical tools preferred.
  • Exceptional analytical skills with the ability to diagnose root causes and propose effective solutions.
  • Strong communication skills with the ability to build and maintain relationships across technical and nontechnical stakeholders.
  • Highly organized, selfmotivated, and able to manage multiple priorities in a fastpaced environment.
New York, NY Salary Range
$150,800—$188,500 USD
Denver, CO Salary Range
$138,000—$172,500 USD
Charlotte, NC Salary Range
$125,600—$157,000 USD

All employees are responsible for adherence to the Judi Health Code of Conduct including the reporting of non-compliance. This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.

We provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

By submitting an application, you agree to the retention of your personal data for consideration for a future position at Judi Health. More details about Judi Health's privacy practices can be found athttps://www.judi.health/legal/privacy-policy.

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