Resp & Qualifications PURPOSE: The Senior Business Analyst supports critical Medicare pharmacy business through advanced data analysis, reporting, and operational PBM oversight. This role interprets complex data to develop reports and presentations, ensures compliance with contractual and regulatory requirements, and supports quality and performance objectives across pharmacy operations.
ESSENTIAL FUNCTIONS: Pharmacy Operational & Analytical Functions
- Analyze pharmacy operational data and claims activity to identify trends, risks, and improvement opportunities.
- Monitor claims processing and review pharmacy benefit coding for accuracy and compliance.
- Perform prescription drug event (PDE) review, correction, and retraction activities.
Medicare Regulatory & Compliance Functions
- Review and analyze monthly, quarterly, and annual data related to coverage determinations, redeterminations, and grievances.
- Track, document, and trend Medicare and PBMrelated issues to support compliance, audit readiness, and corrective action activities.
- Participate in internal and external audits and third-party reviews, including formulary administration, improper payment, and Acumen reporting.
Reporting & Decision Support
- Prepare and submit routine and ad hoc Medicare KPI reports, including PBM performance and compliance tracking.
- Provide analytical support and recommendations to pharmacy leadership to inform operational and strategic decisions.
Communication & Stakeholder Support
- Monitor member and provider communications for accuracy, timeliness, and regulatory compliance, including letters, explanations of benefits, and website content.
- Coordinate with internal and external stakeholders to ensure PBM activities align with pharmacy operations and member experience expectations.
- Serve as a point of contact for vendor performance oversight and issue resolution.
Quality & Continuous Improvement
- Support quality initiatives through provider and member outreach, participation in committees, and support of member events.
- Conduct process analysis and contribute to studies aimed at improving efficiency, quality, and compliance.
- Adapt to shifting priorities and manage multiple concurrent initiatives, providing operational support as needed.
QUALIFICATIONS:Education Level: Bachelor's Degree in Business, Information Technology, Computer Science 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.
Experience: 5 years progressive experience in business analysis, systems analysis, testing or other analytical experience.
Preferred Qualifications:- Demonstrated ability to deliver high quality, effective deliverables on-time and be a significant contributor to the development of cost-effective solutions.
- Proven understanding of business analysis core competencies
- Certified Pharmacy Technician
- Experience at a health plan or PBM.
- Knowledge of CMS guidance and regulations.
- Experience with pharmacy claims processing systems.
Knowledge, Skills and Abilities (KSAs)- High-level of knowledge and understanding of business products and services.
- Microsoft Office applications usage.
- Excellent communication skills both written and verbal.
- Ability to analyze, organize, and prioritize work while meeting multiple deadlines.
- 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: $73,728 - $146,432
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).
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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