Benefit Validation Specialist I - Direct Placement Compensation: Annual Salary up to $29,000 plus benefits (commensurate with experience). Location: Guaynabo, PR Company Description: Our client is a leading pharmacy benefit manager committed to improving patient health and reducing healthcare costs. The company offers innovative solutions for health plans, employers, and government agencies. Our client culture emphasizes innovation, collaboration, and patient-centric care. Position Description: Benefits Validation Specialist I is focused on keeping benefit set up configuration and claim adjudication to the highest quality standards. Will attend inquiries and consultations from internal and external clients. Should be able to find trends, issues, and present recommendations. Responsibilities + Claims Validation: Reviews claim activity against benefit setups to ensure accurate processing according to client-approved requirements. This includes analyzing claim adjudication, payments, co-pays, deductibles, and denial reasons. + Testing and Quality Assurance: Prepares test grids and scenarios and executes manual and batch testing in UAT and Production/Live environments within OneArk. This ensures accurate claim processing and benefit application. + Defect Resolution: Troubleshoots and resolves reported claim defects related to adjudication, payments, and denials. Identifies root causes, implements solutions, and documents findings. + Issue Identification and Solutioning: Proactively identifies potential issues impacting claim processing and benefit application. Develops and proposes potential solutions to management. + Documentation and Reporting: Organizes and documents findings, results, and resolutions in a standardized, client-facing format. This ensures clear communication and audit trails. + Performance Monitoring and Accountability: Accountable for claim accuracy, including meeting established KPIs and contributing to annual assessments. This demonstrates ownership and commitment to quality. + Project Management and Prioritization: Effectively manages multiple client assignments and projects simultaneously, prioritizing tasks and adhering to project deadlines and schedules. Works independently under minimal direction. + Continuous Improvement: Creates educational materials based on audit results and identified needs. Maintains full knowledge of all validations performed within the department and contributes to process improvements. Qualifications + 1 – 2 years of clinical experience in a healthcare environment or at a pharmacy benefit manager (PBM). + 1+ years in a medical, insurance, or pharmacy claims environment (less than 5 years of experience preferred). + Strong data analysis and problem-solving skills. + Proficient in Microsoft Office applications (Word and Excel). + Excellent verbal and written communication skills, including the ability to tailor communication to the audience. + Ability to handle multiple tasks, meet deadlines, and follow up timely, + Pharmacy claims experience, Pharmacy Tech experience and Quality and claims audit experience. + Bi-lingual (English/Spanish Education- Certification + Pharmacy Technician associate degree from an accredited institution (where mandated by law) + Open to newly licensed technicians + Nationally Certified Pharmacy Technician (CPhT) certification (required). + Current, valid, and unrestricted state or Puerto Rico Pharmacy Technician license/registry certificate. Benefits: + Health & Wellness: + Exceptional Health Insurance: We've got you covered! We pay 80% of your health insurance premiums, including comprehensive coverage for medical, dental, vision, and hospital visits. Basic life insurance is also included. + Generous Life Insurance: Basic life insurance coverage at 100% company-paid: + Employee: Up to $50,000 (based on annual salary) + Spouse: 25% of employee's coverage (up to $50,000) + Children: $5,000 per child + Supplemental Life Insurance: Boost your protection with voluntary life insurance, up to 5 times your annual salary (combined limit with basic life insurance is $100,000). + Work-Life Balance: Enjoy the flexibility of remote work options. + Wellness Program: Your well-being is our priority. We offer a comprehensive wellness program that includes: + Mental health care assistance + Substance abuse treatment support + Confidential Employee Assistance Program (EAP) for personal and family matters + On-site health clinics + Wellness initiatives, health fairs, and educational conferences + Gym Membership Reimbursement: Stay active and healthy! We'll reimburse up to $25 per month for your gym membership. + Long-Term Disability: Protect your income! 100% company-paid long-term disability insurance (through Universal Insurance) provides 60% of your annual salary (up to $6,000) if you're unable to work due to a non-work-related illness or injury. + Time Off & Leave: + Generous Vacation Time: Enjoy 15 days of vacation per year, accrued at 10 hours per month. + Paid Sick Leave: Accumulate 12 sick days per year (8 hours per month). + Birthday Leave: Celebrate your special day with a paid day off! + Paid Parental Leave: + Maternity Leave: 8 weeks of 100% paid leave for new mothers. + Paternity Leave: 5 days of 100% paid leave for new fathers. + Bereavement Leave: 3 days of paid leave for the loss of a close family member. + Paid Holidays: Enjoy paid holidays throughout the year (varies). + Personal Leave: 5 additional personal days per year for your convenience. + Other Leave: We also provide leave for FMLA, SINOT, jury duty, military service, and other legal obligations. + Financial Security & Growth: + Retirement Plan (401k): Plan for your future! We fully match your contributions up to 3% of your salary, plus an additional $0.25 match for every dollar you contribute up to 6% of your salary. That's a potential 9% match! + Performance Bonuses: Recognizing and rewarding your contributions with performance-based bonuses. + Christmas Bonus: $600 Christmas bonus (subject to eligibility requirements). + Referral Program: Earn $1,500 for successfully referring qualified candidates. + Recognition & Development: + People of Excellence Award: We celebrate outstanding performance. + Engagement Activities & Team Buildings: Build strong connections with your colleagues. + Professional's Week: Dedicated time for professional development and appreciation. + Ongoing Education: We invest in your growth with opportunities for continuous learning and development using cutting-edge technology. Physical and Mental Demands A typical office environment requires talking, hearing, sitting, standing, and walking. May require lifting to 25 pounds. Reasonable accommodation may be provided for individuals with disabilities. Environmental and Working Conditions Professional office environment. Requires use of standard office equipment (computers, phones, etc.). May require evening or weekend work. About RCM: RCM is a leading provider of Business, IT, and Engineering Services to over 1,000 clients in the commercial marketplace. RCM partners with clients to define, implement and manage a broad range of technologies across multiple platforms, systems, and networks. Our broad geographic presence ensures that a proven and reliable tactical and strategic capability is available and deployable virtually everywhere in North America. Equal Opportunity Statement: RCM is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. Pay Transparency: RCM believes in transparency and fairness in compensation. We are committed to providing our employees with competitive salaries that reflect their skills, experience, and contributions to our organization. As part of our commitment to pay transparency, we want to provide you with as much information as possible about our compensation practices. Disclaimer: This job posting is intended to describe the general nature and the level of the work to be performed. It is not intended to include every job, duty and responsibility specific to the position. RCM reserves the right to amend and change responsibilities to meet business and organizational needs as necessary.