Senior Pharmacy Network Configuration Analyst

What you'll do

In a few words...

Abarca is igniting a revolution in healthcare. We built our company on the belief that with smarter technology we are redefining pharmacy benefits, but this is just the beginning...

As a Senior Pharmacy Network Configuration Analyst, you will be responsible for serving as a primary support for pharmacy network participation and pricing configuration within our Pharmacy Benefit Management (PBM) environment. This role is focused on configuring, validating, and supporting network setup, contracted rates, and pricing logic across Medicare, Medicaid, Commercial, and Employer clients to ensure accurate claims adjudication and compliance with regulatory and client requirements. You will also provide senior-level triage support, lead root cause analysis, and drive process improvements across network and pricing workflows.

The fundamentals for the job...

• 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.

What we expect of you

The bold requirements...

• 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.
• We are proud to offer a flexible hybrid work model which will require certain on-site workdays (Puerto Rico Location Only).
• 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).

Nice to haves...

• 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.

Physical requirements...

• Must be able to access and navigate each department at the organization's facilities.
• Sedentary work that primarily involves sitting/standing.

At Abarca we value and celebrate diversity. Diversity, equity, inclusion, and belonging are guiding principles of Abarca and ensure Abarca's workforce reflects the communities it serves. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.

Abarca Health LLC is an equal employment opportunity employer and participates in E-Verify. "Abarca Health LLC does not sponsor employment visas at this time"

The above description is not intended to limit the scope of the job or to exclude other duties not mentioned. It is not a final set of specifications for the position. It's simply meant to give readers an idea of what the role entails.

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