PBM Integration Specialist

Description
If you're looking for a career that provides affordable health benefit solutions to the people who support some of the most vital industries, we're looking for you.

At Pinnacle Claims Management, we are an innovative third-party administrator (TPA) that provides a full-suite of comprehensive and customized health benefits administration services for self-funded companies, including health management and wellness solutions, and pharmacy benefit management. We are also a proud contracted partner with Covered California. As part of the Western Growers Family of Companies, we are committed to providing our employees with everything they need to succeed and grow. We know that taking care of our clients starts with taking care of our employees.

As a keystone of our philosophy, we recognize that every person on our team comes to us with a unique background, history and story that adds strength to our organization. Additionally, employees are encouraged to recognize that there isn't a work life and a home life, there is one life. This recognition throughout the organization emphasizes the value of finding a healthy and happy balance in every employee's life. One way this is realized for employees of Pinnacle Claims Management is flexible work arrangements with work-from-home, in-office or hybrid options.

With competitive compensation packages, premier investment support, enriching personal development and more, we strive for our employees' job satisfaction and success.

Compensation: $73, $100,208.62 with a rich benefits package that includes profit-sharing.
Job Description Summary
This position reports to the Director, PBM. The PBM Integration Specialist is responsible for supporting the day-to-day management of existing third-party vendors. This role plays a key part in ensuring the accuracy and integrity of vendor data, monitoring file feeds and integrations, and coordinating with internal teams to maintain smooth operational workflows. They will lead initiatives related to achieving organizational objectives and meeting contractual obligations. In addition, this position creates, and monitors reports as required for process control and production effectiveness and completes special projects.
Qualifications

• BS/BA degree in Business, Finance, Economics, or a related discipline with three (3) to five (5) years of experience in the healthcare industry, preferred.
• Two (2) to four (4) years of data and/or analytical experience in the healthcare industry, with a strong focus on processing pharmacy, dental, and vision claims data and vendor collaboration, highly desired.
• Proficient in Excel, Access, and familiar with data management or reporting tools (e.g., Power BI, SQL).
• Strong ability to manage multiple projects efficiently in a high-demand environment.
• Excellent interpersonal skills, with the ability to build and maintain effective relationships with internal stakeholders and external vendors.
• Experience working with pharmacy, dental, and vision claims data, ensuring accurate processing and analysis.
• Ability to communicate and influence across departments, vendors, and clients to facilitate seamless data processing.
• Proven success in defining analysis scope, meeting deadlines, and troubleshooting data discrepancies.
• Experience working independently and cross-functionally to define data requirements and ensure accurate claims data processing.
• Strong organizational skills, attention to detail, and commitment to maintaining data confidentiality and integrity.
• Home router with wired Ethernet (wireless connections and hotspots are not permitted).
• A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)
• A functioning smoke detector, fire extinguisher, and first aid kit on site.

Duties And Responsibilities
Claims Data Processing & Vendor Collaboration

• Oversee the processing, validation, and reconciliation of pharmacy claims data from multiple sources.
• Review and reconcile consumer claim data files from third-party vendors, coordinating invoicing and payment processes with operational and accounting teams.
• Collaborate with external vendors to ensure accurate and timely claims data exchanges, troubleshoot issues, and implement corrective measures.
• Coordinate with IT and operational teams to maintain and enhance claims data processes, ensuring compliance with industry standards and regulations.
• Monitor claims data for errors, discrepancies, and processing failures, working proactively to resolve issues.
• Assist in vendor onboarding by defining claims data processing specifications, testing data exchanges, and ensuring seamless integration into operational workflows.

Analytics & Reporting

• Develop and maintain reports analyzing pharmacy, dental, and vision claims data, vendor performance, and network efficiency.
• Gather, assess, and interpret quantitative data from clients and vendors to support strategic pricing proposals and operational enhancements.
• Utilize SQL, Excel, and data visualization tools to perform in-depth quantitative and qualitative analysis.
• Support internal and external partners by providing data-driven insights to optimize performance and cost efficiency.
• Identify opportunities to improve data integrity, streamline claims data workflows, and enhance vendor data management processes.
• Work closely with PBM colleagues and external vendors to capture business needs and implement process improvements related to claims data reporting and analytics.

Project Operations

• Identify and implement solutions to non-standard requests by solving complex claims data processing challenges.
• Provide guidance and direction on claims data-related project risks, progress, and resolution strategies.
• Develop and deliver project status reports, outlining deliverables, vendor correspondence, and outcomes.
• Present findings and recommendations to leadership regarding claims data processing enhancements and vendor performance.

Other

• Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, be self-accountable, create a positive impact, and be diligent in delivering results.
• Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.
• Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data.
• Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit).
• All other duties as assigned.

Physical Demands/Work Environment
The physical demands and work environment described here represent those that an employee must meet to successfully perform this job's essential functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.