Abarca Health · 3 hours ago
Senior Pharmacy Network Configuration Analyst
United States
Full-time
Remote
Senior Level
6+ years expAbarca is igniting a revolution in healthcare, focusing on redefining pharmacy benefits through smarter technology. In this role, you will be responsible for pharmacy network participation and pricing configuration within the Pharmacy Benefit Management environment, ensuring accurate claims adjudication and compliance with regulatory requirements.
Health CareInformation Technology
No H1B
Responsibilities
Serve as the primary support for pharmacy network and pricing configuration, including network setup, contracted rates, and pricing rules for new client implementations and existing plan changes
Configure and maintain pricing logic to ensure accurate claims adjudication aligned with client documentation and contractual requirements
Support configuration changes related to pharmacy network participation and pricing structures across multiple lines of business
Perform unit testing to validate adjudication outcomes against expected network and pricing rules
Perform Quality Control and Quality Assurance reviews to ensure accuracy and consistency within network and pricing configuration processes
Participate as needed in UAT testing for product enhancements/updates to confirm operational and business user acceptance
Research and resolve claims adjudication issues related to network participation and pricing discrepancies, including root cause analysis, impact assessment, and corrective actions
Provide first-tier triage support for network and pricing-related claims processing issues, ensuring performance aligned to SLAs/SLOs
Take ownership of project-based configuration work, ensuring timelines, deliverables, and outcomes are met
Collaborate across configuration, adjudication, product, and operational teams to execute accurate network and pricing solutions
Identify network and pricing functionality required to meet client outcomes and support implementation execution
Continuously develop and maintain an in-depth understanding of Darwin (proprietary adjudication platform) logic related to network and pricing configuration
Stay current with Medicare, Medicaid, and state regulatory requirements, ensuring configurations remain compliant
Provide consultation and peer review for network and pricing configuration practices and design standards
Support the Sr. Analyst in documenting client plan standards, configuration processes, and operational procedures
Evaluate network and pricing workflows and recommend process improvements that advance efficiency, consistency, and quality outcomes
Support onboarding and knowledge transfer by contributing to documentation and training resources as needed
Qualification
Required
Associate or bachelor's degree. (In lieu of a degree, equivalent relevant work experience may be considered.)
6+ years of hands-on experience in PBM Pharmacy Network & Pricing configuration, including pharmacy network setup and pricing rule implementation
2+ years of experience using SQL and Excel to validate network participation and pricing outcomes in claims adjudication
Strong analytical skills with the ability to identify network/pricing issues, determine root cause, and drive corrective actions
Ability to collaborate effectively across technical and operational teams
Excellent oral and written communication skills
This position requires availability to work in a specified time zone or working schedule, accommodating the business needs of our clients and team members
This position may require availability for on-call hours, including evenings, weekends, and holidays, to promptly address emergent issues or provide necessary support as dictated by operational demands (if applicable)
Preferred
Experience with pharmacy network contracting, pricing models, or MAC list management
Experience in a healthcare non-retail pharmacy or PBM setting
Prior experience working directly with Darwin or similar adjudication platforms
Benefits
Flexible hybrid work model
Equal employment opportunities
Prohibit discrimination and harassment
Company
Abarca Health
Abarca Health is an information technology company that offers healthcare IT services
501-1000 employees
Funding
Current Stage
Late StageLeadership Team
Adriana Ramirez
President & COO
Recent News
News is my Business
2025-10-31
News is my Business
2025-03-27
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