The PBM Data Operations Coordinator supports data exchange operations across eligibility and claims accumulator processes. This role provides technical and analytical expertise for electronic data interchange (EDI) transactions, including eligibility (834) and claims accumulator feeds (e.g., 837).
The Coordinator serves as a subject matter expert and key liaison between internal teams, clients, third‑party administrators (TPAs), and external vendors. Responsibilities include onboarding new clients, overseeing file transmission workflows, resolving discrepancies, enhancing data interfaces, and ensuring the accuracy and timeliness of member data processing.
Must work on site 5 days a week
Key Responsibilities
Eligibility & EDI File Operations
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Capture and analyze client requirements, mapping specifications, and goals during onboarding.
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Support carrier and vendor testing for new eligibility file implementations.
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Monitor inbound and outbound eligibility file exchanges; proactively identify and resolve errors.
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Research, troubleshoot, and remediate issues related to electronic eligibility data and system processing.
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Perform quality reviews of eligibility tasks, fixes, and enhancements.
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Manage file handling, tracking tools, and reporting accuracy.
Claims Accumulator & Benefit Data Operations
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Conduct upfront analysis of accumulator feeds from clients, TPAs, and medical carriers.
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Ensure timely and accurate upload of accumulator amounts into the system.
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Proactively identify and correct discrepancies or file issues.
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Analyze edit reports and coordinate corrective actions.
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Serve as the business owner for Integrated Max Out-of-Pocket (TMOOP) processing.
Cross‑Functional Responsibilities
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Provide requirements for new interfaces and system enhancements related to eligibility and accumulator data.
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Collaborate with IS and other internal teams to address process gaps, inefficiencies, or platform improvements.
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Assist with user acceptance testing (UAT) for system development requests.
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Participate in internal and external meetings, calls, and vendor/client discussions.
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Provide technical support to implementation teams and external stakeholders.
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Document fixes, enhancements, and process updates to ensure operational quality.
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Other duties as assigned.
Qualifications:
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Ability to work independently and take initiative.
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Experience testing, analyzing, researching, verifying, entering, or correcting electronic data.
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Experience with eligibility (834) files and/or accumulator-related data feeds.
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Working knowledge of electronic file formats such as 834 or 837.
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Proficiency in Microsoft Excel (moderate skill level).
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Strong analytical and critical-thinking skills.
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Organizational skills and attention to detail.
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Verbal and written communication skills.
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Ability to multitask, prioritize, and work effectively with teams.
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Ability to analyze and research data to identify and resolve issues.
Preferred Qualifications
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1+ years’ experience in electronic claims accumulator transmission.
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Experience with custom client file layouts and healthcare industry EDI standards.
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Experience with TPA, carrier, or PBM environments.
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Familiarity with post-edit reporting or accumulator discrepancy analysis.
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Prior involvement with UAT or system development initiatives.
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Competitive salary
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Vacation and Sick/Personal Time
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Medical Insurance
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Hearing Program Discount
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Short‑ and Long‑Term Disability Insurance
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Life Insurance
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Flexible Spending Account
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401(k)
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Employee Referral Program
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Employee Recognition Programs
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Tuition Reimbursement
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Professional Development and Training
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