PBM Claims Adjudication Specialist

AffirmedRx is on a mission to improve health care outcomes by bringing clarity, integrity, and trust to pharmacy benefit management. We are committed to making pharmacy benefits easy to understand, straightforward to access and always in the best interest of employers and the lives they impact. We accomplish this by bringing total clarity to business practices, leading with clinical approaches, and utilizing state-of-the-art technology.

Join us in improving health care outcomes for all! We promise to do what’s right, always.

Position Summary:

The PBM Claims Adjudication Specialist is a deeply technical, hands-on role responsible for building and maintaining client eligibility and accumulator files that ensure AffirmedRx’s data is always comprehensive, always accurate. Reporting to the Manager, Data Operations, this person develops new client eligibility files and accumulator files, builds coding automations to streamline file processing, and sets up and manages SFTP connections for secure client file transmission. Deep, hands-on PBM claims adjudication experience is required — this role exists because getting eligibility and accumulator data right requires someone who genuinely understands how claims adjudicate, not just how files are formatted. Experience working with the RxSense platform is a significant plus.

What you will do:

Client Eligibility File Development:

Design, build, and configure new client eligibility files based on client-specific requirements and benefit plan designs

Translate client eligibility rules and benefit structures into accurate file specifications and processing logic

Test and validate eligibility files prior to go-live to confirm accuracy before they reach production

Accumulator File Development & Management:

Design, build, and maintain accumulator files reflecting member deductible, out-of-pocket, and benefit accumulator data

Ensure accumulator logic aligns correctly with plan design and claims adjudication rules

Investigate and resolve discrepancies in accumulator data before they affect members or clients

Claims Adjudication Expertise & Application:

Apply deep, hands-on PBM claims adjudication knowledge to inform file design, testing, and issue resolution

Serve as the team’s go-to expert on adjudication logic, NCPDP standards, and claims processing rules

Partner with the Business Analyst, ETL Developer/File Management Analyst, and other Data Operations team members on complex client issues requiring adjudication expertise

Coding Automation:

Develop automations and scripts that streamline file build, testing, and validation processes

Reduce manual, repetitive work across eligibility and accumulator file processing through coding and automation

Maintain and continuously improve existing automations as client needs and file formats evolve

SFTP Setup & Management:

Configure and manage SFTP connections for new and existing client file transmissions

Ensure secure, reliable file transfer setup for all client eligibility and accumulator data exchanges

Troubleshoot SFTP connectivity and transmission issues, escalating and resolving quickly to avoid data gaps

Data Accuracy & Ongoing Maintenance:

Ensure eligibility and accumulator data remains comprehensive and always accurate across all clients

Proactively identify and resolve data discrepancies before they surface as client- or member-facing issues

Support the change control process for any changes to client files, layouts, or related production systems

What you need:

Bachelor’s degree in a related field, or equivalent experience

Required: deep, hands-on experience with PBM claims adjudication, including how claims process, adjudicate, and interact with eligibility and accumulator data

7+ years of direct PBM experience building and maintaining client eligibility files and accumulator files

Experience working with the RxSense platform is a significant plus

Strong knowledge of NCPDP standards, claims processing rules, and benefit design as they relate to file build and testing

Experience with SFTP setup, configuration, and management for secure client file transmission

Excellent troubleshooting and problem-solving skills, with the judgment to catch data issues before they become client- or member-facing problems

High attention to detail, given the accuracy-critical nature of eligibility and accumulator data

Comfortable working both independently and as part of a small, collaborative team

Mission-driven, humble, and supportive; holds high standards while fostering learning rather than blame

Aligns with AffirmedRx values, promoting trust, accountability, and innovation

Willingness to travel (10%-20%)

What you get:

To impact industry change in the pharmacy benefits management space, while delivering the highest quality patient outcomes

To work in a culture where people thrive because when OUR team thrives, OUR business thrives

Competitive compensation, including health, dental, vision and other benefits

Note:

AffirmedRx is committed to providing equal employment opportunities to all employees and applicants for employment. Remote employees are expected to maintain a professional work environment free of distractions to ensure optimal performance and collaboration.