Sr Contract Monitoring Analyst-Medicare Part D Job in Providence 02903, Rhode Island US
At Blue Cross Blue Shield of Rhode Island (BCBSRI), diversity and inclusion are central to our core values and strengthen our ability to meet the challenges of today's healthcare industry. BCBSRI is an equal opportunity, affirmative action employer. We provide equal opportunities without regard to race, color, religion, gender, age, national origin, disability, veteran status, sexual orientation, gender identity or expression.
Conduct in-depth pharmacy claim and data analyses to monitor Medicare Part D Pharmacy Benefit Manager (PBM) contractual obligations, validate system configuration, claim adjudication accuracy and ensureCMSrequirements are being met. Extract and analyze pharmacy claims, formulary data and benefit information to monitor and ensure optimal adjudication results. Measure performance guarantees as part of the overall assessment of contract performance. Conduct annual rebate and brand/generic guarantee rate reconciliations. Serve as subject matter expert and project lead on various PBM related initiatives. Act as liaison between the business and applicable contract-related vendors to facilitate escalation of issues, problem resolution, system enhancements and project implementations.
ESSENTIAL JOB FUNCTIONS
- Monitor Medicare Part D PBM contract including, but not limited to, rebate amounts, claim pricing and benefits, formulary coverage/tiering application and contractual performance measures. Performance measures include validation of claim adjudication accuracy from both a pricing and benefit perspective. Participate in User Acceptance Testing to ensure system corrections are accurate.
- Establish and conduct monitoring activities centered around keyCMSaudit findings and best practices including, but not limited to, formulary administration, point of sale edits, coverage, tiering, claim reject reports.
- Provide internal departments with monitoring and audit support of Medicare Part D claims to ensure CMScompliance. Provide the necessary support to internal departments during CMSaudits to document ongoing monitoring activities. Serve as subject matter expert with respect to the annual benefit changes and rules associated with the Medicare Part D program
- Monitor and reconcile annual PBM contract rebate, brand and generic effective rate guarantees, review PBM invoices for claims and administrative expenses to ensure contract rates and fees have been invoiced properly by the PBM.
- Participate in and/or lead cross departmental workgroups.
- Extract pharmacy claims, benefit and eligibility data for studies. Gather any necessary enrollment, formulary, pricing, benefit and trend information from internal departments and the PBM.
- Perform other duties as assigned.
QUALIFICATIONS:
Minimum Education and Experience:
- Bachelor's Degree in Business Management, Finance, Mathematics, Computer Science, Statistics or related field or an equivalent combination of education and work experience.
- Five to seven years experience in quantitative business analyses and statistical modeling (preferably healthcare related).
- Proven analytical experience using Enterprise Guide SAS, database query capabilities and ability to evaluate data at various levels of detail (preferably Enterprise Guide SAS).
Preferred Education, Additional Qualifications and Experience:
- Advanced Degree in one of the above areas
- Subject Matter Expert on Medicare Part D and CMS requirements
- Knowledge of BCBSRI systems
- Knowledge of PBM claim adjudication systems
- Knowledge of healthcare related websites and software packages
- Pharmacy Benefit Manager (PBM) technical and operational experience
Required Knowledge, Skills, and/or Abilities:
- Knowledge of pharmacy data (claims, fees, eligibility, benefits, formulary) and statistical analyses
- Knowledge of healthcare terminology
- Knowledge of pharmacy claim adjudication including pricing and benefit structure
- Knowledge of First Data Bank and Medi-Span (NDCpricing)
- Enterprise Guide SAS programming skills
- Microsoft Word, Access, PowerPoint and Excel skills
- Business Objects (Crystal) skills
- Strong analytical and problem solving skills
- Demonstrated ability to work independently, organize projects, manage multiple priorities simultaneously, meet deadlines and integrate input and work products from other functional areas
- Ability to work independently with minimal guidance from Management
- Ability to see the “big picture” to achieve the best outcomes/resolutions
- Ability to effectively communicate the results of complicated analyses in a clear and concise manner to the Pharmacy Department and Senior Management (Directors, Assistant Vice Presidents, Vice Presidents)
- Ability to efficiently handle multiple priorities concurrently
- Ability to exercise sound judgment
- Ability to take initiative in finding solutions to difficult and/or sensitive problems
- Ability to effectively represent the interests and needs of the Contract Monitoring Team at various meetings and workgroups
