[Remote] Senior Data Analyst, Quality Review - Medicare Pharmacy Claims Part D & Part B)
Note: The job is a remote job and is open to candidates in USA. Blue Cross NC is seeking a Senior Data Analyst to join their Government Pharmacy Programs Department. The Senior Data Analyst, Quality Review – Medicare Pharmacy Claims will ensure accurate and compliant adjudication of Medicare pharmacy claims, conducting quality oversight and validating benefit and pricing logic while adhering to CMS regulations.
Responsibilities
- Perform comprehensive quality reviews of Medicare Part D and Part B pharmacy claims, including retail, mail order, LTC, specialty, and medical‑benefit drug claims
- Validate accurate application of:
- Medicare Part D phases (Deductible, Initial Coverage, Catastrophic)
- Low‑Income Subsidy (LIS) cost‑sharing
- MOOP accumulations
- PDE data elements and claim submission logic
- MAC list pricing
- Pharmacy discounts and dispensing fee accuracy by pharmacy type
- Identify irregular prescribing and/or dispensing patterns for investigation and referral to PBM, internal audit and SIU teams
- Review Part B drug claims for correct HCPCS coding, units of service, allowable charges, and coordination with medical claims
- Identify claim adjudication errors related to pricing, benefit configuration, formulary status, utilization management edits, and CMS rules
- Partner with Compliance to ensure claims accuracy consistent with CMS guidance, Medicare manuals, and plan sponsor requirements
- Support internal and external audits (CMS program audits, CTM, PDE validation, RADV support activities) by identifying findings, impact analysis, remediation documentation, and Corrective Action Plans
- Conduct root cause analysis on quality findings; partner with Compliance, IT, operations, and PBM teams to implement corrective actions
- Develop and maintain quality metrics, dashboards, and trend reports related to Medicare claims accuracy and risk
- Serve as a subject matter expert for Medicare pharmacy claims processing
- Provide guidance and mentorship to peers and colleagues, and contribute to Medicare‑specific quality standards, SOPs, and training materials
Skills
- Bachelor's degree or advanced degree (where required)
- 5+ years of experience in related field
- In lieu of degree, 7+ years of experience in related field
- 5+ years of Medicare pharmacy claims, PBM, or managed care experience
- Direct experience with Medicare quality review, compliance, auditing, or PDE support strongly preferred
- Strong expertise in Medicare Part D pharmacy claims adjudication, including PDE requirements and CMS benefit rules
- Working knowledge of Medicare Part B drug billing, HCPCS, and pharmacy-to-medical claim integration
- Solid understanding of CMS regulations, including: Cost-sharing and benefit phase logic, LIS and subsidy calculations, Formulary management and UM edits (PA, ST, QL)
- Advanced analytical skills with experience performing claim analyses and error trending
- Proficiency in Excel; experience with prescription adjudication systems and Medicare reporting tools preferred
- Strong documentation, communication, and cross-functional collaboration skills
- Pharmacy Technician certification or equivalent pharmacy background is a plus
Benefits
- Annual Incentive Bonus*
- 401(k) with employer match
- Paid Time Off (PTO)
- Competitive health benefits and wellness programs
- Medical, dental, and vision coverage along with numerous health and wellness programs
- Parental leave and support plus adoption and surrogacy assistance
- Career development programs and tuition reimbursement for continued education
- Work-life balance, flexibility, and the autonomy to do great work
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