Remote Position
Primary Function/General Purpose of Position
The Pharmacy Business & Performance Analyst will assist in administrating the pharmacy benefits program by maintaining the pharmacy benefit formulary, facilitating administrative appeals, auditing pharmacy benefit claims, and analyzing pharmacy benefits data. The Pharmacy Benefits Managed Care Analyst will have a variety of job responsibilities within the pharmacy benefits team that may encompass various activities.
Essential Job Functions
Organizes and facilitate administrative appeals received from members and providers through the PBM
Works with benefits pharmacist to compose appeals cases, disseminate appeal requests to appeals committee members, collate responses from committee members, and deliver response letters to members and providers
Analyzes and audit pharmacy claims with a focus on but not limited to significant changes in drug cost, appropriate use of wellness program claims, and claims with inappropriate quantities and day supplies
Collaborates with operations and clinical pharmacy team to troubleshoot patient care issues and requests
Assists I&T and data users to understand vendor file layouts, develop data files, and establish new data file transmissions with vendors. Also help to facilitate change to existing file transfers when necessary
Assigned tasks may include administration of accumulators, data base management, data file transfers to and from vendors, creation and maintenance of drug pricing and formulary files with vendors, and reconciliation of rebates and drug claim discounts
Attends and participate in meetings with clients and business partners as needed.
Communicates with and educate existing health plan members, physician offices, or pharmacies via inbound and outbound calls including cost savings opportunities.
This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job-related duties as required by their supervisor, subject to reasonable accommodation.
Licensing/Certification
CPT Certification provided by the National Health Career Association or Pharmacy Technician Certification Board (PTCB) certification and registration with State Board of Pharmacy (preferred)
Education
High School Diploma/GED
Work Experience
Minimum of 1-year experience in one of the following: Managed Care, Retail, Ambulatory, Outpatient, Hospital, Acute Care, or Home Infusion pharmacy (required)
Minimum of 1-year experience with pharmacy financial or business analysis and/or system in a health plan or PBM (preferred)
Minimum of 1-year experience in customer service and/or healthcare (preferred)
Training
Completion of ASHP/ACPE tech training program - or - pharmacy technician training via Armed Forces/Veterans Affairs - or respective state department approved career tech high school program (preferred)
Skills
Knowledge of PBM benefits set up, claims processing, and related regulatory requirements. Electronic Medical Records (EMR)Prioritization
Computer skills – word processing, spreadsheets, PowerPoint®, drug databases (required)
MS Office (Excel) (required)
Dashboard design (preferred)
Knowledge/training in Microsoft Access (preferred)
Familiarity with various software, equipment, and technology necessary to provide pharmacy services
Knowledge of pharmacy services within acute and ambulatory care environments
Knowledge of laws and regulations regarding pharmacy and/or pharmacy benefits/managed care pharmacy
Performance Improvement
Attention to Detail
Customer Service
Problem Solving
Active Listening
Verbal and Written Communication
Professional Judgement
Telephone etiquette
Time, project, and change management
Working independently
Organization
Providing feedback
Many of our opportunities reward* your hard work with:Comprehensive, affordable medical, dental and vision plans
Prescription drug coverage
Flexible spending accounts
Life insurance w/AD&D
Employer contributions to retirement savings plan when eligible
Paid time off
Educational Assistance
And much more
*Benefits offerings vary according to employment status
All applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, sexual orientation, gender identity, age, genetic information, or protected veteran status, and will not be discriminated against on the basis of disability. If you'd like to view a copy of the affirmative action plan or policy statement for Mercy Health – Youngstown, Ohio or Bon Secours – Franklin, Virginia; Petersburg, Virginia; and Emporia, Virginia, which are Affirmative Action and Equal Opportunity Employers, please email recruitment@mercy.com. If you are an individual with a disability and would like to request a reasonable accommodation as part of the employment selection process, please contact The Talent Acquisition Team at recruitment@mercy.com