SUMMARY:

The Healthcare Analyst position is responsible for assisting Medicare Advantage PPO, HMO and PDP plans meet CMS compliance requirements for PBM oversight, CMS reporting, review member eligibility and reporting, benefit set up and testing. Other related skills may be required to perform this job. The maximum hourly rate reflects budget estimates only and does not reflect the final negotiated rate.

RESPONSIBILITIES/TASKS:

Develops and improves work flows and business processes within area(s) to improve customer service, decrease operational costs, and improve overall quality.

Assists Customer Service with questions and clearly communicates responses to inquiries.

Assist in CMS and other data audits conducted by CMS and internal audit teams

Identifies and/or analyzes business problems and devise procedures for solutions to the problems.

Effectively leads projects in order to produce desired results.

Responsible for corporate communication of project results.

Recommends and assists with implementing standard policies and procedures.

Assures that corporate compliance is communicated, implemented, and monitored on an ongoing basis.

Participates in systems testing, develops procedures/controls, and provides recommendations for the ongoing improvement of the updated process.

Assists personnel (both internal and external) by answering questions, supplying information, and training.

Develops and maintains an effective working relationship with customers.

Participates in group or committee discussions.

Education:

Bachelor’s degree in a related field is preferred. Relevant combination of education and experience may be considered in lieu of degree. Continuous learning, as defined by the Company’s learning philosophy, is required.

EXPERIENCE:

• Four (4) years’ experience in a related field is required (prefer health plan or PBM).

• Experience with Microsoft Office applications including Excel, Word and Outlook.

• Must have data analysis, and problem resolution skills. Spreadsheet and/or Database skills.

• Experience resolving eligibility and pharmacy claims related issues.

• Experience with responding to CMS requests regarding pharmacy claims timely.

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:

Knowledge of pharmacy claim processing and Medicare guidance related to Part D products.

Organizational skills and ability to prioritize; must be able to lead multiple activities with varying timelines.

Ability and willingness to learn and take on more responsibilities based on activities with the team.

Experience with PBM systems and tools.

Ability to understand questions from external areas and articulate timely and accurate responses.

Analyst experience required with proven experience in operational analysis, data analysis, and problem resolution type activities.

Analytical, organizational, planning and problem solving skills

Understanding and knowledge of the business, products, programs, corporate organizational structure (including functional responsibilities), and basic research principles/methodologies

Ability to plan, organize, direct, and control projects.

Excellent written and verbal communication skills.

Ability to lead and contribute to process improvement projects.

Ability to read and interpret documents such as data flows, process flows, technical diagrams, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of organization.

Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.

Administer and adhere to corporate and departmental policies, practices and procedures.

Category Analyst

Function Information Technology

Req ID JN -112024-121675