PBM Integration Specialist

Join to apply for the PBM Integration Specialist role at Pinnacle Claims Management
, a leading third‑party administrator offering comprehensive health benefits and pharmacy benefit management services to self‑funded companies and partners such as Covered California.

We provide affordable health benefit solutions to vital industries and support our employees with flexible work arrangements, competitive compensation, and growth opportunities.

Compensation: $73,237.64‑$ plus profit‑sharing and a comprehensive benefits package.

This position reports to the Director of PBM. The PBM Integration Specialist manages day‑to‑day vendor relationships, ensures vendor data integrity, monitors file feeds and integrations, and leads initiatives to meet contractual and organizational objectives. The role also creates and monitors process control reports and completes special projects.

• BS/BA degree in Business, Finance, Economics, or a related discipline with three to five years of experience in the healthcare industry.
• Two to four 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.
• 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 independently and cross‑functionally to define data requirements and ensure accurate claims data processing.
• 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.
• Strong organizational skills, attention to detail, and commitment to maintaining data confidentiality and integrity.
• Maintain a HIPAA‑compliant workstation and utilize appropriate security techniques to ensure HIPAA‑required protection of all confidential/protected client data.

• 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.

• 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.

• 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.

Mid‑Senior level

Full‑time

Project Management and Information Technology

Hospitals and Health Care