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Medicare Part D Claims Analyst

Pharmpix Guaynabo, PR

  • Expired: over a month ago. Applications are no longer accepted.
Job Description


  1. Responsible for conducting quality check and reviews of Medicare Part D claims samples on a routine basis to ensure proper Medicare Part D claims parameter computations as well as suggesting new edits or claim alerts or reviews that could be applied in real time to ensure consistent and quality claims processing for Part D clients. 
  2. Responsible for independently researching PDE errors related to clinical program parameters on claim transitions and providing mitigating steps for error resolutions.   Analyze claims processing concerns related to Part D claims processing. 
  3. Works with internal teams to define audit universe/sample requirements. Responsible for conducting quality checks and reviews of results of universe/sample pulls and preparing written analysis of testing results. 
  4. Evaluate new processing business requirements and analyze claims requirements in order to ensure technical claims solutions are achieving the desired claim adjudication results.  
  5. Responsible for reviewing and responding to Accumen PDE Edits reviews within established timelines and communicating to plan sponsors with resolution confirmations.  
  6. Responsible for the distribution of PDE Error Summary Reports created monthly after submissions as well as the analysis of error trends noted in reporting that would need escalation.  
  7. Responsible for the calculation and creation of adjustment claims for processing based upon technical, clinical and client eligibility errors.   
  8. Identification of errors relating to claims processing to isolate and mitigate resolution of issues or errors.   This process involves identifying the issue and calculating the amounts or differences based upon drug status, claim type, formulary code and phase of the benefit to figure the appropriate amount for adjustment. 
  9. Responsible for the daily analysis of FIR transfers for benefit changes and the identification of impacted claims for intervention and review.
  10. Communicate and analyze guidance related to PDEs to ensure system setting and processes meet standards or requirements.   
  11. Responsible for the documentation of processes and procedures related to PDE claims processing, error handling, and operational procedures.  
  12. Responsible for communicating PDE processes and errors to clients.  This includes tracking issues, providing follow up and documenting resolution for the client.  Acts as a point of contact for clients on PDE issues and participating in client meetings as needed.
  13. Create tracking and reporting for management briefings and executing day-to-day project management activities related to routine, scheduled, and ad-hoc or escalated activities related to PDEs.  
  14. Responsible for the updating and maintenance of PDE Error Manual Processes for Plan Sponsors.   Reviews manual with clients as needed to assist in client training and education on client responsibilities in the PDE error handling process.  
  15. Ensures connectivity for new clients as a PDE submitter by processing and completing required set-up paperwork. Ensures new testing and certification requirements are completed and reported to clients
  16. Conducts reviews of intra-plan transfers of claims and TrOOP balances to ensure claims and balances are appropriate with benefit design parameters.   Identifies scenarios of over and under payments and responds or processes situations as required by regulations.
  17. Create, suggest, develop, and implement new reporting for clients for PDEs. 
  18. Respond to PDE Audit requests for substantiation of PDEs by working with Pharmacy Audits Team to coordinate and facilitate client or audit requests. 
  19. Collaborate with IT on programming new requirements and issues for correct claims processing. 
  20. Responsible for facilitating internal PDE Team meetings and submission timelines and cut off for claims processing and adjustments for internal staff members.  
  21. Reviews new edit codes to identify responsible lead team and prepares documentation updates to support and respond to new edits and error codes. 
  22. Coordinates with IT staff for timely PDE submissions and error resolution.
  23. Works collaboratively to communicate and analyze guidance related to PDEs to ensure System setting and processes meet new standards or requirements.  
  24. Responsible for the creation and updating of compliance submission calendar based upon CMS standards and processes for timely submissions and error working. 
  25. Demonstrate a consistently positive, respectful and constructive attitude with internal staff and external customers.
  26. Maintains an expert knowledge on Medicare Part D claims processing and operations processes relating to CMS regulatory provisions as they relate to this position. 
  27. Follows and ensures compliance of company and department policies and procedures.  Communicates any concerns with leadership.
  28. Identify and develop solutions to maximize department processes and procedures.
  29. Maintains a working knowledge of changes in pharmacy practice, laws, Medicare Part D regulations, and drugs applicable to the performance of daily duties.


  • At least two years of experience as working with point of sale claims processing at a Medicare Part D Health Plan or Pharmacy Benefit Manager with direcT experience working with Prescription Drug Events (PDEs). 
  • Experience with Medicare Part D Manuals and Standards required. 
  • Pharmacy Claims Processing Computer System experience required – knowledge of NCPDP Claims transactions standards and fields. 


  • Bachelor degree in Finance, Information Technology or Healthcare related field; or equivalent experience.


The person must have:

  • Internet accessibility with or more than 10MB speed.
  • Personal cellphone.
  • Personal computer.

EEO Employer Minorities/Females/Disable/Veterans



Guaynabo, PR
00968 USA


Finance and Insurance

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