Pharmacy Pricing Appeals Analyst

Location: Hybrid 3 days in Charlotte, NYC or Denver office

Position Summary:

The Pharmacy Pricing Appeals Analyst is responsible for the end-to-end intake, review, investigation, documentation, and processing of pharmacy pricing appeals. This role supports timely and accurate appeal resolution by validating pharmacy appeal requests, researching PBM and pharmacy claims, reviewing invoices and acquisition cost documentation, analyzing reimbursement outcomes, documenting appeal decisions, and maintaining appeal records in tracking systems and workflow tools.

The analyst will work closely with the Manager, Pharmacy Pricing Appeals, as well as cross-functional partners in Analytics, Network Operations, Finance, Compliance, and related operational teams. The role requires strong attention to detail, pharmacy claims knowledge, analytical judgment, and the ability to manage multiple appeal requests through established deadlines and documentation standards.

Position Responsibilities:

• Claims Investigation – Ability to research pharmacy claim details, validate identifiers and document findings
• Analytical Thinking – Ability to compare pharmacy claim payment data against invoice and acquisition cost
• Pharmacy Claims Knowledge – Understanding of PBM and pharmacy claims terminology, adjudication, and reimbursement concepts
• Communication – Clear written and verbal communication with internal stakeholders and pharmacy contacts
• Data Integrity – Commitment to accurate, complete and audit ready records

Required Qualifications:

• Minimum 2 to 4 years of PBM, pharmacy operations, pharmacy claims, pharmacy reimbursement, network operations, or healthcare claims experience
• Associates Degree preferred; equivalent combination of education and pharmacy/PBM experience may be considered
• Direct experience researching, validating, or resolving pharmacy claims
• Experience in reviewing pharmacy claim data, adjudication results, Rx numbers, NDC’s and pharmacy identifiers, invoice documentation, and operational records with strong accuracy
• Experience working with claims tracking tools, workflow tickets, spreadsheets, and operational documentation
• Working knowledge of pharmacy reimbursement concepts and PBM claims processes
• Intermediate to advanced Microsoft excel skills, including accurate data entry, filtering, sorting and working with templates

Preferred Qualifications:

• Certified Pharmacy Technician [CPhT] preferred, but not required
• Intermediate coding experience preferred, but not required
• Retail, specialty, mail-order, managed care or PBM pharmacy experience
• Experience with pharmacy pricing, network reimbursement, MAC appeals, acquisition cost review, or related pharmacy reimbursement processes
• Experience using internal pharmacy adjudication systems, reporting, or data output tools to support claims research
• Experience with compliance-driven operational processing and documentation standards