Claims Consultant
Core
Administer and process pharmacy benefit claims for self-funded employer health plans, acting as a liaison between clients, pharmacies, PBMs, and internal teams to resolve issues and ensure compliance.
Role type
Claims Consultant (Healthcare Operations)
Builds
Pharmacy benefit claim resolutions and accurate adjudication outcomes for self-funded organizations
Domain
Healthcare / Pharmacy Benefits Administration
Required skills
Claims adjudication, Pharmacy benefit administration, Regulatory compliance, Data reconciliation, Root cause analysis, Client liaison
Preferred skills
Self-funded plan experience, PBM/TPA knowledge, Spanish language, Claims systems proficiency
Technologies
Microsoft Excel, Claims adjudication systems, Reporting platforms
Responsibilities
Review and resolve pharmacy benefit claim issues; Analyze adjudication outcomes for discrepancies; Coordinate with pharmacies, PBMs, and TPAs; Research eligibility and benefit design; Monitor payment accuracy and compliance; Assist in claims data auditing; Support client implementation projects.
Seniority
Mid-level, hands-on IC