- Responsible for serving as the liaison between the business, and internal and external Pharmacy and PBM partners in translating complex business needs into operational pharmacy benefit application of requirements into coding platform.
- Primary duties may include, but are not limited to:
- Analyzes complex pharmacy book of business needs to determine optimal means of meeting those account-specific needs.
- Determines specific pharmacy account business application requirements to address complex business needs.
- Develops project plans and identifies and coordinates resources, involving those outside the unit.
- Works with internal/external stakeholders to ensure requirements will be incorporated into pharmacy benefit design and testing.
- Acts as a resource to cross-functional stakeholders to address questions/issues relative to pharmacy benefit operations and execution.
- May provide direction and guidance to team members and serves as an expert for the team.
- Provide support for the development and administration of specialized pharmacy benefit functions including: pharmacy benefit builds, system functionality and capability consultation, adjudication logic, pre and postproduction auditing.
- Leads the preparation and submission of detailed updates of benefit changes to Pharmacy Benefit Manager (PBM),
- Oversees the design and execution of user acceptance testing (UAT) of changes and ensures such changes are implemented on time, and coordinates post implementation verification that claims are processed as intended.
- Support cross-functional teams to ensure accuracy of pharmacy claims activity and sustain pharmacy benefit integrity.
- Create and maintain databases to track pharmacy benefits performance and trending; and provide oversight for pharmacy claim issue management and resolution, to include documentation, resolution and trending of claims issues
- Analyze data and summarize performance using summary statistical procedures.
- Develop and analyze pharmacy benefits performance reports (e.g. for claims data, provider data, utilization data) and provides notations of performance deviations and anomalies.
- Create and publish periodic reports, as well as any necessary ad hoc reports.
- May require taking pharmacy benefits issue/escalation(s) and devising best way to develop appropriate diagnostic and/or tracking data that will translate pharmacy benefit configuration and design into integrity-driven resolution.
- Performs detailed analysis to define root cause for reported issues and facilitate issue resolution.
- Analyzing, reporting and developing recommendations on data related to multiple, varied business metrics.
- Requires:
- a BA/BS and minimum of 5 years business analysis experience;
- previous medical health care, analytical experience, or project management experience, or
- Some experience with claims processing and/or benefit coding
- any combination of education and experience which would provide an equivalent background.
- Knowledge of systems capabilities and business operations is strongly preferred.
- Preferred Qualifications
- Healthcare experience required
- SAS Enterprise Guide, Microsoft Office Suite (Excel, Word, Access, PowerPoint, Outlook, etc.) required.
- Basic SQL and Visual Basic understanding preferred.
- SQL Management Studio, Power BI, Tableau, Teradata SQL preferred.
- Healthcare claims experience required.
- Pharmacy claims experience preferred.
- Experience in pharmacy operations, with knowledge of drugs, drug classes, formulary implementation
- Managed Care experience preferred.
- Experience with relational databases and knowledge of query tools and statistical software is required.
- Ability to manipulate large sets of data.
- Strong analytical, organizational, presentation, and problem-solving skills.
- Must have excellent written and verbal communication skills, advanced critical thinking and problem-solving skills.
- Proficient to Advanced skills in: Excel/Access applications to include data manipulation and reporting analysis withcomplex formulas.
- Pharmacy Technician Certification Board (PTCB - a national pharmacy technician association), a plus but not required.
- Pharmacy Benefit Manager (PBM) experience highly preferred.
- This position supports a sensitive, high-touch book of business with strategic demands and precise execution required;
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Business Analyst III (US) is posted on all sites within our Diversity Job Network.
