Adjudication Analyst

Job Description

Location: Remote – U.S. Based

TalentLNX is actively seeking a knowledgeable and detail-oriented Adjudication Analyst for a full-time, remote opportunity with an innovative pharmacy benefit organization. This role is an excellent fit for professionals who have direct experience working in pharmacy claims adjudication and are ready to bring their technical skills to a mission-driven, collaborative team.

If you’ve previously supported or owned adjudication workflows—working through plan design, eligibility, accumulator alignment, or claim-level troubleshooting—you’ll thrive in this role. You’ll be surrounded by team members who value precision, problem-solving, and a shared commitment to improving patient access to care.

Responsibilities:

• Claims Analysis & Resolution: Investigate and resolve complex pharmacy claims issues involving plan setup, eligibility mismatches, accumulator discrepancies, and adjudication platform logic.
• Internal Support: Serve as a go-to subject matter expert for adjudication-related questions across operational, client services, and engineering teams.
• Issue Escalation & Troubleshooting: Triage escalated claims issues from internal partners and contribute to timely, accurate resolution with appropriate documentation.
• Testing & Validation: Participate in user acceptance testing (UAT) for adjudication enhancements, benefit updates, and configuration changes to ensure clean functionality.
• Process Improvement: Collaborate cross-functionally to streamline adjudication workflows and support continuous improvement efforts.
• Reporting & Documentation: Analyze data trends, document root cause findings, and contribute to knowledge-sharing around adjudication best practices.

Work Environment:

This is a work from home role with a highly structured workflow. The position requires strong attention to detail, comfort with multi-system navigation, and a high level of accountability in handling sensitive pharmacy benefit data.

Qualifications:

• Previous experience in an adjudication analyst or adjudication support role is required
• 2+ years of experience working with pharmacy benefit platforms, plan builds, or claims adjudication
• Strong understanding of eligibility files, accumulators, formulary logic, and benefit configuration
• Proficiency with Microsoft Excel and comfort working with large datasets
• Excellent analytical, problem-solving, and communication skills
• Proven ability to work independently and prioritize complex tasks
• Experience with PBM platforms, payer systems, or adjudication testing environments is a strong plus

Schedule 

• Full-time – Remote
• Monday – Friday shifts between 8:00 AM – 5:00 PM EST
• Flexibility may be required during system releases or special projects

Salary Range: Compensation for this role ranges from $50,000 to $60,000 per year (approximately $24.00 to $29.00 per hour), depending on experience and qualifications.

Interview Process:

• Initial Screening – TalentLNX Recruiting Team
  A 20–30 minute phone conversation designed to learn more about your background and career goals. We’ll share additional details about the role, clarify expectations, and ensure this opportunity aligns with what you’re seeking in your next position—whether it’s culture, compensation, growth potential, or long-term career direction.

• Final Interview – Adjudication Team Members (Video Interview)
  A focused conversation around claims logic, platform troubleshooting, and your hands-on experience supporting adjudication workflows.

Equal Opportunity Employer: TalentLNX is committed to equal employment opportunity and prohibits discrimination and harassment of any kind. We are dedicated to building a diverse workforce and fostering an inclusive work environment where all employees and candidates are treated with respect and dignity. We do not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, or any other protected status under applicable law. We actively seek to recruit, develop, and retain talented individuals from diverse backgrounds, and we encourage all qualified candidates to apply for our job opportunities.