RxCompass Claims Operations Analyst

RxCompass Claims Operations Analyst

Position Overview

The Claims Operations Analyst is responsible for supporting claims processing, loading, quality review, reconciliation, aging visibility, and issue resolution across RxCompass and Variable Copay vendor programs. This role will process and review incoming vendor claims submissions, validate file accuracy, identify discrepancies, support claims dispute resolution, and maintain clear visibility into claim status throughout the full claims lifecycle.

Reporting to the Supervisor, Data & Analytics, RxCompass/VCP , this position will work closely with Data & Analytics, Finance, Business Integration, Vendor Management, Operations, and external vendors to ensure claims are processed accurately, timely, and in accordance with defined workflow expectations.

The Claims Operations Analyst plays a key role in preventing claims backlogs, supporting accurate client billing and vendor payment, maintaining claims lifecycle visibility, and escalating risks before they create financial, operational, or member service impact.

Role and Responsibilities


Claims Processing & Quality Review

• Process, load, and quality review incoming vendor claims submissions across multiple vendors, ensuring accuracy and adherence to strict processing timelines.
• Receive, review, and track vendor claims files submitted through SFTP, FTP, email, or other approved channels.
• Validate vendor claims submissions for completeness, formatting, accuracy, eligibility, and processing readiness.
• Manipulate and manage various Excel file formats as part of daily claims processing, reconciliation, and reporting workflows.
• Execute limited SQL queries and Snowflake worksheets in support of claims processing, validation, reconciliation, and reporting needs.

Claims Reconciliation & Issue Resolution

• Reconcile vendor claim files against internal processing records, payment files, remittance reports, and outstanding vendor balances.
• Identify, document, and communicate claims errors, file issues, rejections, and discrepancies to vendors and internal teams in a timely manner.
• Track rejected, incomplete, or pending claims and coordinate follow-up through resolution.
• Assist with claims disputes and reconciliations in collaboration with cross-functional teams.
• Support vendor balance reviews and help identify differences between vendor-reported balances and internal claims/payment status.
• Submit and track internal tickets to the appropriate departments for resolution and escalation as needed.

Claims Aging, Reporting & Escalation

• Track claims received, claims processed, claims rejected, claims pending, and claims resolved.
• Maintain claims aging visibility and escalate delayed, unresolved, or high-risk items according to defined thresholds.
• Prepare routine claims status updates, aging summaries, backlog reports, and open-item trackers for leadership review.
• Support visibility into oldest outstanding claim dates, pending dollar exposure, processing volume, and claims requiring cross-functional action.
• Communicate claims status, risks, blockers, and support needs clearly to the Supervisor, Data & Analytics and other internal stakeholders.

Vendor & Cross-Functional Collaboration

• Maintain consistent communication with vendors and stakeholders throughout the claims lifecycle.
• Partner with Finance to support visibility into claims ready for client billing and vendor payment.
• Partner with Business Integration, Vendor Management, Data & Analytics, and Operations to resolve claims-related blockers and vendor workflow issues.
• Support Site of Care vendor management workflows as needed, including review of claims involving J-Codes and/or procedure codes.

Process Improvement & Documentation

• Support the development and maintenance of standard operating procedures, trackers, and reporting tools related to vendor claims processing and reconciliation.
• Identify opportunities to improve automation, reporting accuracy, workflow efficiency, and backlog prevention.
• Support testing or validation of system changes related to vendor claims processing.

Compliance & Confidentiality

• Maintain confidentiality of sensitive medical information and comply with HIPAA Privacy and Security Rules.
• Abide by all obligations under HIPAA related to Protected Health Information.
• Report any suspected HIPAA violations to the Compliance Officer and/or Human Resources.
• Attend and complete all required HIPAA training.
• Job responsibilities may evolve as business needs change.

Supervisory Responsibility

• None.

Required Skills and Competencies

• Strong attention to detail and ability to identify discrepancies across claims files, reports, balances, and payment data.
• Strong Excel skills, including ability to work with multiple file formats, filters, formulas, pivot tables, lookups, and reconciliation workbooks.
• Ability to execute limited SQL queries and Snowflake worksheets with direction.
• Ability to review claims files for accuracy, completeness, and formatting issues.
• Strong organizational, follow-up, and time management skills.
• Ability to manage recurring deadlines and multiple vendor workstreams.
• Strong written and verbal communication skills.
• Ability to communicate claims errors, discrepancies, blockers, and risks clearly to vendors and internal stakeholders.
• Ability to escalate risks timely and appropriately.
• Familiarity with claims files, remittance files, vendor reporting, or payment reconciliation.
• Ability to work with SFTP/FTP file exchange processes.
• Problem solving and root-cause analysis.
• Ability to work independently with limited direction.
• Ability to communicate technical or claims-related issues to non-technical stakeholders.
• Thoroughness, accuracy, accountability, and sound judgment.
• Microsoft Office Suite proficiency.

Preferred Skills and Experience

• Experience with pharmacy claims, PBM operations, specialty pharmacy, copay assistance, Site of Care, or healthcare vendor operations.
• Familiarity with pharmacy claims terminology, NDCs, eligibility logic, rejection logic, J-Codes, procedure codes, remittance reporting, and vendor claim submissions.
• Experience with SQL, Snowflake, SSRS, Power BI, or other reporting tools.
• Experience maintaining claims aging, vendor reconciliation, backlog, or open-item trackers.
• Experience supporting cross-functional workflows involving Finance, Operations, Data, Business Integration, and external vendors.
• Experience submitting and tracking internal tickets through resolution.
• Experience working in a HIPAA-regulated environment.

Position Type and Expected Hours of Work

• Full-time/Salaried/Exempt.
• Some flexibility in hours is allowed, but the employee must be available during the "core" work hours of 8:00 AM to 5:00 PM CT. We cover clients from the West to East Coast, work times must be adjusted to cover meetings in all time zones. Ability to work extended hours, weekends, and holidays pursuant to industry demands.

Travel

No travel is expected for this position.

What We Have to Offer

Our Benefits package is designed to keep our employees happy and healthy - physically, mentally and financially.

• Medical, Dental, and Vision insurance
• Disability and Life insurance
• Employee Assistance Program
• Remote work options
• Generous Paid-Time Off
• Annual Reviews and Development Plans
• Retirement Plan with company Match immediately 100% vested

Required Education and Experience

• High school diploma or equivalent required.
• Associate's degree preferred
• 1-3 years of equivalent experience in PBM, healthcare claims, claims adjudication, claims reconciliation, vendor operations, or related healthcare operations required.

Preferred Education and Experience

• Associate's or Bachelor's degree in Business, Healthcare Administration, Information Systems, Data Analytics, Finance, or a related field preferred.
• Experience in pharmacy claims, healthcare data, vendor reconciliation, billing support, finance operations, or data/reporting operations preferred.
• Intermediate Excel experience strongly preferred.
• SQL, Snowflake, SSRS, or Power BI experience preferred but not required.
• Pharmacy benefit management, specialty pharmacy, Site of Care, or healthcare vendor operations experience preferred.

RxCompass, LLC provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability, or genetics. In addition to federal law requirements, RxCompass, LLC complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

RxCompass, LLC expressly prohibits any form of workplace harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status. Improper interference with the ability of RxCompass, LLC employees to perform their job duties may result in discipline up to and including discharge. EOE M/F/D/V