PBM Operations Associate
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Job Description
PBM Operations Associate configuring and testing pharmacy benefits for Rightway’s healthcare navigation platform. Maintaining claims rules, documentation, and data operations across client implementations.
Responsibilities:
- Review client benefit design documentation for completeness and accuracy, flagging open items and partnering with implementation and client success to resolve gaps
- Configure client benefit designs in the claims adjudication platform, including plan parameters, copay structures, inclusions and exclusions, and utilization management edits
- Support new client implementations and mid-year plan changes
- Develop and execute test claim scenarios to validate benefit setup before go-live
- Perform ongoing monitoring and regression testing after changes
- Research, document, and correct identified defects through resolution
- Research and resolve inquiries related to claims adjudication and benefit configuration
- Partner with client success to communicate findings and remediation steps
- Work cross-functionally with product, client success, implementation, and formulary teams
- Maintain audit-ready documentation of benefit setup, testing evidence, and internal controls
- Track implementation and plan-change work, keeping status, ownership, and deadlines current
Requirements:
- Bachelor’s degree preferred; relevant experience considered for exceptional candidates
- 1-3 years of PBM experience in claims adjudication, benefit configuration, or testing/QA
- Pharmacy Technician certification or related pharmacy experience highly desirable
- Strong attention to detail with the ability to trace a claim outcome back to its configuration driver
- Comfortable navigating ambiguity and working from incomplete requirements
- Able to ask the right questions and exercise sound judgment when documentation does not cover every scenario
- Comfortable working in Excel, Smartsheet, and claims platforms
- Able to manage multiple client deliverables against firm deadlines
- Clear written communication and documentation skills
- Ability to keep stakeholders informed without being prompted
Benefits:
- Bonus
- Equity
- Equal Opportunity Employer and inclusive culture
- Rightway health guides and human experts for members (company product/service description, not an employee benefit)
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