Note: The job is a remote job and is open to candidates in USA. Rightway is a healthcare company offering a pharmacy benefit management (PBM) model focused on affordability, transparency, and consumer empowerment. The PBM Operations Associate will configure, test, maintain, and monitor client benefit designs and claims adjudication rules while resolving issues and coordinating with cross-functional teams.
Responsibilities
- Review client benefit design documentation for completeness and accuracy, flagging open items and partnering with implementation and client success to resolve gaps prior to configuration
- Configure client benefit designs in the claims adjudication platform, including plan parameters, copay structures, inclusions and exclusions, and utilization management edits, for both new client implementations and mid-year plan changes
- Develop and execute test claim scenarios to validate benefit setup prior to go-live, and perform ongoing monitoring and regression testing to confirm accuracy after changes. Research, document, and correct identified defects through to resolution
- Research and resolve inquiries related to claims adjudication and benefit configuration, partnering with client success to communicate findings and remediation steps
- Work cross-functionally with product, client success, implementation, and formulary teams to ensure benefits are built and operating according to signed client requirements
- Maintain complete, audit-ready documentation of benefit setup, testing evidence, and internal controls in support of audit and internal quality standards
- Track work across implementation and plan change trackers, keeping status, ownership, and deadlines current so cross-functional partners have real-time visibility
Skills
- 1-3 years of PBM experience in claims adjudication, benefit configuration, or testing/QA
- Strong attention to detail with the ability to trace a claim outcome back to its configuration driver
- Comfortable navigating ambiguity; able to work from incomplete requirements, ask the right questions, and exercise sound judgment when documentation doesn't cover every scenario
- Comfortable working in structured tools (Excel, Smartsheet, claims platforms) and managing multiple client deliverables against firm deadlines
- Clear written communicator who documents decisions and keeps stakeholders informed without being prompted
- Bachelor's degree preferred; relevant experience considered for exceptional candidates
- Pharmacy Technician certification or related pharmacy experience highly desirable
Benefits
- Bonus
- Equity
Company Overview
Company H1B Sponsorship