PBM Integration Specialist (50929)

Job Description Summary

This position reports to the Manager, PBM Analytics & Plan Administration. The PBM Integration Specialist is responsible for supporting the day-to-day management of existing third-party vendors. This role plays a key part in ensuring the accuracy and integrity of vendor data, monitoring file feeds and integrations, and coordinating with internal teams to maintain smooth operational workflows. They will lead initiatives related to achieving organizational objectives and meeting contractual obligations. In addition, this position creates, and monitors reports as required for process control and production effectiveness and completes special projects.

Duties And Responsibilities

Claims Data Processing & Vendor Collaboration

• Oversee the processing, validation, and reconciliation of pharmacy claims data from multiple sources.
• Review and reconcile consumer claim data files from third-party vendors, coordinating invoicing and payment processes with operational and accounting teams.
• Collaborate with external vendors to ensure accurate and timely claims data exchanges, troubleshoot issues, and implement corrective measures.
• Coordinate with IT and operational teams to maintain and enhance claims data processes, ensuring compliance with industry standards and regulations.
• Monitor claims data for errors, discrepancies, and processing failures, working proactively to resolve issues.
• Assist in vendor onboarding by defining claims data processing specifications, testing data exchanges, and ensuring seamless integration into operational workflows.

Analytics & Reporting

• Develop and maintain reports analyzing pharmacy, dental, and vision claims data, vendor performance, and network efficiency.
• Gather, assess, and interpret quantitative data from clients and vendors to support strategic pricing proposals and operational enhancements.
• Utilize SQL, Excel, and data visualization tools to perform in-depth quantitative and qualitative analysis.
• Support internal and external partners by providing data-driven insights to optimize performance and cost efficiency.
• Identify opportunities to improve data integrity, streamline claims data workflows, and enhance vendor data management processes.
• Work closely with PBM colleagues and external vendors to capture business needs and implement process improvements related to claims data reporting and analytics.

Project Operations

• Identify and implement solutions to non-standard requests by solving complex claims data processing challenges.
• Provide guidance and direction on claims data-related project risks, progress, and resolution strategies.
• Develop and deliver project status reports, outlining deliverables, vendor correspondence, and outcomes.
• Present findings and recommendations to leadership regarding claims data processing enhancements and vendor performance.

Other

• Utilize all capabilities to satisfy one mission - to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, be self-accountable, create a positive impact, and be diligent in delivering results.
• Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.
• Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data.
• Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit).
• All other duties as assigned.

Physical Demands/Work Environment

The physical demands and work environment described here represent those that an employee must meet to successfully perform this job's essential functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.