Pharmacy Benefits Analyst

2 weeks ago

Southfield, Michigan, United States OpTech Full time
Job Title: Health Care Analyst

Why work at OpTech?
OpTech is a woman-owned organization that values your insights, fosters your development, and consistently supports you. At OpTech, you will receive health and dental benefits from your first day of employment, along with training opportunities, flexible/remote work arrangements, career advancement possibilities, a 401K plan, and competitive compensation.

POSITION OVERVIEW:

ROLE SUMMARY:
  • The Health Care Analyst role involves aiding Medicare Advantage PPO, HMO, and PDP plans in fulfilling CMS compliance mandates related to PBM oversight, CMS reporting, and benefit configuration and testing.
KEY RESPONSIBILITIES:
  • Enhances and refines workflows and business processes to elevate customer service, reduce operational expenses, and enhance overall quality.
  • Supports Customer Service with inquiries and effectively communicates responses.
  • Assists in CMS and other data audits conducted by CMS and internal audit teams.
  • Identifies and analyzes business challenges and formulates procedures for effective solutions.
  • Successfully leads projects to achieve intended outcomes.
  • Responsible for corporate communication regarding project outcomes.
  • Proposes and aids in the implementation of standard policies and procedures.
  • Ensures ongoing communication, implementation, and monitoring of corporate compliance.
  • Engages in systems testing, develops procedures/controls, and offers recommendations for continuous process improvement.
  • Assists both internal and external personnel by providing information and training.
  • Cultivates and maintains effective working relationships with clients.
  • Participates in group or committee discussions.
REQUIRED QUALIFICATIONS:

EXPERIENCE:
  • A minimum of four (4) years of experience in a relevant field is essential (preferably in health plans or PBM).
  • Proficiency in Microsoft Office applications, including Excel, Word, and Outlook.
  • Must possess data analysis and problem-solving skills, including spreadsheet and/or database capabilities.
  • Experience in resolving eligibility and pharmacy claims-related issues.
  • Familiarity with responding to CMS inquiries regarding pharmacy claims in a timely manner.
  • Additional related skills may be necessary for this position.
SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:
  • Understanding of pharmacy claim processing and Medicare guidelines pertaining to Part D products.
  • Strong organizational skills and the ability to prioritize; capable of managing multiple activities with varying timelines.
  • Willingness to learn and take on additional responsibilities as team activities evolve.
  • Experience with PBM systems and tools.
  • Ability to comprehend inquiries from external sources and provide timely and accurate responses.
  • Proven experience in operational analysis, data analysis, and problem resolution activities.
  • Strong analytical, organizational, planning, and problem-solving skills.
  • Familiarity with the business, products, programs, corporate structure, and basic research principles/methodologies.
  • Ability to plan, organize, direct, and manage projects effectively.
  • Excellent written and verbal communication skills.
  • Capacity to lead and contribute to process improvement initiatives.
  • Ability to interpret documents such as data flows, process flows, technical diagrams, and procedure manuals.
  • Competence in delivering presentations to groups of clients or employees.
  • Ability to apply common sense to execute instructions provided in written, oral, or diagram form.
  • Capability to address problems involving multiple concrete variables in standardized situations.
  • Adherence to corporate and departmental policies, practices, and procedures.
EDUCATION:
  • A Bachelor's degree in a related field is preferred.
  • A relevant combination of education and experience may be considered in lieu of a degree.
  • Continuous learning, as defined by the Company's learning philosophy, is mandatory.
OpTech is an equal opportunity employer committed to fostering a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, pregnancy, status as a parent, disability, age, veteran status, or other characteristics as defined by federal, state, or local laws.

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