Reporting Pharmacy Benefit Analyst (Hybrid)

Resp & Qualifications



PURPOSE:
Supports the Maryland Medicaid pharmacy program by performing pharmacy benefit related activities and operational support. Help drive critical pharmacy business decisions by analyzing metrics and designing reports. Communicate results to stakeholders and provide suggestions based on findings.

ESSENTIAL FUNCTIONS:

• Collaborates with stakeholders to understand pharmacy data needs to create reports that meets the needs of the pharmacy business. Identifies functional requirements through process analysis, review of documents and procedures, and interviews and meetings with stakeholders.
• Manage the Hepatitis C prior authorization process. Obtains clinical information from prescribers to ensure all aspects of clinical guidelines are addressed for pharmacist review. Enters authorization in pharmacy claims system.
• Analyzes pharmacy data from internal reports and external Pharmacy Benefit Manager reports and develops observations and findings based on analysis. Presents findings in quarterly Delegation Oversight Committee. Creates and test reports utilizing feedback and revisions into reporting products. Conducts quality control, communicates findings, and obtains sign-off from stakeholders to implement reports into production. Prepares adhoc pharmacy analysis, research moderately complex issues, and develops reports in support of reporting requirements, analyzes and interprets data, and makes recommendations to improve pharmacy reporting processes
• Research benefit coverage and claims related inquiries escalated from internal member/enrollee facing departments including pharmacy overrides, high dollar pharmacy claims reviews and more. Follows up with member in response to inquiry and documents in clinical system of record. Researches and prepares all clinical and administrative records for cases open for pharmacy reviews, grievances and appeals. Handles certain levels of case reviews independently and/or triages to a clinician as appropriate for clinical determination.
• Manages the process, workflows, and reporting for committees and pharmacy programs including but not limited to Pharmacy and Therapeutics Committee, Quality Improvement Committee, and Corrective Managed Care Committee. Maintains in depth knowledge of pharmacy Medicaid benefits including knowledge of MDH and CMS guidance and regulations applicable to pharmacy benefits.

SUPERVISORY RESPONSIBILITY:
Position does not have direct reports but is expected to assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources.

QUALIFICATIONS:

Education Level: Bachelor's Degree in Business Administration or related field OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Licenses/Certifications Upon Hire Preferred:

• Data Management\Certified Analytics Professional (CAP).

Preferred Qualifications:

• Proven track record of turning data into meaningful analysis, presenting to business stakeholders, and driving value for the business. Experience developing Return on Investment (ROI) and present to stakeholders and management. Ability to see the big picture and to focus on details when necessary.

Knowledge, Skills and Abilities (KSAs)

• Strong research and investigative skills.
• Proficient in Microsoft Office programs.
• Ability to maintain effective interpersonal relationships.
• Excellent communication skills both written and verbal.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
  
  
  

Salary Range: $51,264 - $101,816


Salary Range Disclaimer


The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Department


Government Programs Specialty


Equal Employment Opportunity


CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Where To Apply


Please visit our website to apply:


Federal Disc/Physical Demand


Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US


Must be eligible to work in the U.S. without Sponsorship

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