Prescription Benefits Analyst (hybrid)

PURPOSE OF THE JOB

• Responsible for internal and external functions that support accurate claim processing for medications.

QUALIFICATIONS

REQUIRED QUALIFICATIONS

Required Work Experience

Experience in pharmacy or medical field

• Level 1 - 3 years
• Level 2 - 5 years
• Level 3 - 5 years
• Level 4 - 6 years

Experience in prescription benefit administration

• Level 1 - 1 year
• Level 2 - 3 years
• Level 3 - 5 years
• Level 4 - 6 years

Experience working in vendor applications (rebate, web tools, formulary tools)

• Level 2 - 1 year
• Level 3 - 2 years
• Level 4 - 5 years

Experience in progressive responsibility with allocation of resources and participating in management of complex projects

• Level 4 - 5 years

Required Education

• High-School Diploma or GED

Required Licenses

• N/A

Required Certifications

• N/A

PREFERRED QUALIFICATIONS

Preferred Work Experience

Experience with a pharmacy benefit management or prescription claim administration

• Level 1 - 3 years
• Level 2 - 3 years
• Level 3 - 5 years
• Level 4 - 6 years

Experience with the current BCBSAZ PBM system

• Level 1 - 1 year
• Level 2 - 1 year
• Level 3 - 2 years
• Level 4 - 6 years

Experience with BCBSAZ claims software / systems

• Level 2 - 1 year
• Level 3 - 2 years
• Level 4 - 6 years

Demonstrated experience handling confidential information

• Level 1 - 2 years
• Level 2 - 3 years
• Level 3 - 4 years
• Level 4 - 6 years

Demonstrated experience handling vendor system coding and analytic functions

• Level 3 - 5 years
• Level 4 - 6 years

Demonstrated experience handling complex projects and allocation of resources

• Level 4 - 5 years

Preferred Education

• Associate’s degree in general field of study

Preferred Licenses

• N/A

Preferred Certifications

• N/A

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

LEVEL 1 - PERFORMS JOB FUNCTIONS UNDER CLOSE SUPERVISION OR PEER REVIEW

• Analyze PBM prescription claim and other applicable systems for medication benefit quality and accuracy
• Support internal and external customers with information on benefits applicable to medication claims
• Perform, evaluate, and assist in defining and improving the quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines.
• Administer, interpret, and maintain current working knowledge of required BCBSAZ systems, procedures, forms and manuals
• Communicate recommendations in regard to medication claim processing and benefit decisions.
• Monitor and investigate reported plan set up system issues
• Participates in quality initiatives; including functions that support audits, reporting, evaluation of quality opportunities and concerns, and creation and implementation of corrective actions as requested.
• Resolve escalated member issues
• Research & provide recommendations for accumulations issues
• Logs all benefit setup issues on error tracking reports
• Provide monthly updates on error resolutions and impact reports

LEVEL 2 - PERFORMS JOB FUNCTIONS WITH MINIMAL SUPERVISION

• Communicates issues identified within vendor system effectively to team.
• Communicates issues identified within plan setup testing or another escalated research to team
• Strategizes solutions for issue resolution and communicates plans to team.
• Provides written documentation for desk levels.
• Provides support to other team members when necessary
• Review plan testing documents for minimal accuracy

LEVEL 3 - PERFORMS JOB FUNCTIONS WITH MINIMAL SUPERVISON, ACTS AS SUBJECT MATTER EXPERT

• Primary liaison for Pharmacy Management for applicable benefit design questions
• Primary SME contact for various internal departments within BCBSAZ In regard to pharmacy plan setup and design
• Builds reporting and analyzes data for benefit recommendations to management.
• Review and determine pharmacy benefit setup upon renewal for all benefit plans
• Build and setup all new pharmacy benefits in the pharmacy system; including standard patient pays
• Submit drug code assignments to enrollment for all benefit plans Maintain pharmacy drug code matrix

LEVEL 4 - LEAD - PERFORMS JOB FUNCTIONS AS ASSIGNED AND ALLOCATES RESOURCES AND PROJECT PRIORITIZATION

• Perform quality checks and analysis on drug code setup from other analysts
• Review escalated plan testing questions for accuracy and make corrections as needed
• Setup all complex pharmacy benefit plan designs
• Setup all complex patient pays, and any other design element related to complex pharmacy benefits
• Works with Pharmacy Management Leadership team to identify project prioritization
• Allocates resources to ensure required work is accomplished within defined time frames
• Assigns Tasks to Analysts and Specialists as needed
   

ALL LEVELS

• Each progressive level includes the ability to perform the essential functions of any lower levels and mentor employees in those levels.
• Properly track all pharmacy benefit issues & concerns
• The position requires a full-time work schedule.  Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
• Perform all other duties as assigned.