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Business Analyst, Experienced

1 month ago

Oakland, United States Blue Shield Of California Full time

Your Role

The Pharmacy Transformation team is responsible for the implementation of large-scale, complex pharmacy strategic initiatives and the delivery of high-quality pharmacy services to our members. The Business Analyst, Experienced role will report to the Pharmacy Integrity Manager. This role is critical to supporting daily operations for the Pharmacy Transformation team, including collaboration with multiple Blue Shield of California teams to prevent, detect, correct, and report fraud, waste and abuse (FWA) of pharmacy claims for all lines of business. The Business Analyst, Experienced will be responsible in collecting, evaluating, and reporting potential FWA and high-risk pharmacies. This role works cross-functionally with other teams in Pharmacy Services and the Special Investigations Unit (SIU). 

Your Work

In this role, you will:

  • Partner with cross functional teams to prevent, detect, correct, and report fraud, waste and abuse (FWA) of pharmacy claims for all lines of business
  • Define, develop, and document processes that will contribute to the identification of pharmacy FWA claims review and investigations
  • Define, prepare, and analyze reports for management review
  • Develop clear, concise documentation of FWA research and present recommendations to SIU and FWA Committee
  • Identify, coordinate, and recommend enhancements to cross-functional systems, pharmacy databases, and other information repositories required for business operations
  • Identify opportunities for improvement in operational performance and notifies management of issues and problems requiring immediate attention
  • Provide analytical support for multiple projects simultaneously, establishes work plans, and timelines; coordinate with internal and external sources
  • Act as subject matter expert for pharmacy FWA evaluation and audit processes
  • Participate as part of a team to provide support and back-up to other Pharmacy Integrity team members to ensure that team goals are met
  • Guide the work of others and/or act as leader of cross functional teams, as delegated by Manager
  • Apply advanced professional principles and concepts to complex work assignments
  • Demonstrate knowledge of other discipline beyond one's own

Your Knowledge and Experience

  • Requires a college degree or equivalent experience
  • Requires 3 years of prior relevant experience
  • Advanced knowledge of health care operations and broad understanding of the industry is preferred
  • Advanced knowledge of pharmacy networks, mail and specialty pharmacy operations, healthcare contracting, and claims audit and/or payment is preferred
  • Solid understanding of pharmacy benefit plan design, pharmacy claims processing, and health related insurance products is preferred
  • Solid problem solving, troubleshooting, and analytical skills is preferred
  • Ability to identify, analyze, and resolve problems related to business operations utilizing statistical analysis methodology is preferred
  • Comprehensive knowledge of Microsoft office applications (i.e., Outlook, Word, Excel, and PowerPoint) is preferred
  • Strong documenting, planning, and organizing skills to scope and manage multiple competing priorities is preferred
  • Excellent interpersonal, verbal and written communication skills is preferred
  • Ability to present and communicate complex subjects to all levels is preferred
  • Demonstrated project management skills is preferred

Pay Range:

The pay range for this role is: $66,770.00 to $93,390.00 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.

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