Pharmacy Claims Analyst - Hybrid (Quincy, MA)

POSITION SUMMARY:

Under the direction of the Director of Pharmacy Technology and Informatics or designee, the Pharmacy Business System will drive operational excellence within the team by ensuring the accurate processing of pharmacy claims within a real time system. The Pharmacy Business System Analyst will be involved in all aspects of running a pharmacy claim processing system. The work includes, but is not limited to, creating project documents, including business and technical design document, preforming updates to system configuration list as a part of both new and maintenance projects. This position will also review data files to ensure accuracy and correct processing, preform system testing, and completing analytics.

ESSENTIAL FUNCTIONS:

• Work with business sponsors, stakeholders, technical team and vendor staff on the design and execution of system changes and updates, including but not limited to the creation of design documents, tracking of development progress, execution of testing and post release monitoring.
• Identify, develop, and establish key performance metrics to ensure successful data exchanges within the pharmacy solution, as well as data exchanges with external sources
• Work with both internal and external data submitters to process and correct any problems within their data and establish timelines for subsequent files.
• Be a subject matter expert within the system and be a point person for the creative solutioning of business and operational needs.
• Ensure ongoing accuracy of systems documentation.
• Develop and execute test plans and test cases that comprehensively test software changes as needed.
• Manage the data exchanges between POPS and other organizations including but not limited to EOHHS, UMASS, Managed Care Entities, and various contracted entities to ensure quality and completeness.
• Establish and maintain communications between the various entities that comprise the pharmacy program and within EOHHS as directed, including but not limited to the POPS Vendor, UMMS IT, EOHHS, and Managed Care Entities.
• Creation and monitoring of operational schedules
• Perform file maintenance of business parameters
• Alert leadership of operational issues, and resolution recommendations
• Be able to work independently to solve problems and present finding to other subject matter experts.
• Ability to work within a highly matrixed multi-stakeholder environment.
• Prepare responses and perform work related to Federal and State audits of MassHealth.
• Participate in annual POPS Disaster Recovery exercises.
• Preform analytics within the claims processing system and other systems as required using a variety of analytics tools such as Business Objects, Excel and Cognos.
• Performs other related duties as assigned.

REQUIRED QUALIFICATIONS:
• Bachelor’s degree.
• 2 years of related experience.
• Excellent oral and written communication skills.
• Demonstrated ability to work in complex environment.
• Demonstrated strong problem-solving skills with an ability to take ownership of tasks.
• Demonstrated innovation, flexibility, and creativity.
• Ability to travel to off-site locations.

PREFERRED QUALIFICATIONS:
• Experience working on IT projects, including in a claim adjudication environment.
• Experience with medial claim processing.
• Experience with process flow and process flow documentation.
• Experience within the healthcare system, ideally pharmacy experience.
• Demonstrated understanding of data warehousing and data reconciliation.
• Experience working with federal and state agencies preferred.