Benefits QA Analyst

Overview:

The Quality Assurance – Benefit Analyst (BA) is responsible for ensuring the accuracy and integrity of plan design setup and claims processing within the pharmacy benefits space. This role involves conducting claims-based testing and analysis to validate that client benefit designs are properly implemented and functioning as intended. The ideal candidate will have PBM experience (required) and a strong background in Excel to support data analysis and validation efforts.

Key Responsibilities:

• Plan Design Validation:
  • Review and validate benefit plan setup to ensure accuracy and alignment with client specifications.
  • Identify and resolve discrepancies in plan configuration and system parameters.
• Claims Accuracy & Testing:
  • Perform claims-based testing to verify that claims process correctly per client benefit design.
  • Conduct root cause analysis on claim adjudication issues and discrepancies.
  • Work closely with internal teams to implement necessary adjustments and corrections.
• Data Analysis & Reporting:
  • Utilize Excel and other analytical tools to interpret claims data and validate system outputs.
  • Develop reports and dashboards to monitor quality metrics and identify trends.
  • Provide actionable insights based on data-driven findings.

Qualifications:

• PBM experience required (minimum 2+ years in claims analysis, QA, or plan setup validation).
• Strong proficiency in Excel (advanced functions such as VLOOKUP, pivot tables, and macros preferred).
• Experience with claims processing systems and benefit plan configurations.
• Strong attention to detail and analytical skills to identify discrepancies and ensure accuracy.
• Ability to work collaboratively with cross-functional teams in a fast-paced environment.
• Excellent documentation and communication skills.