Senior Data Analyst, Quality Review - Medicare Pharmacy Claims Part D & Part B)
Blue Cross NCAbout the role
Job Description
We're hiring a Senior Data Analyst to join the Government Pharmacy Programs Department! The Senior Data Analyst, Quality Review – Medicare Pharmacy Claims is responsible for ensuring accurate, compliant adjudication of Medicare Part D and Medicare Part B pharmacy claims. This role performs detailed quality oversight, validates benefit and pricing logic, ensures adherence to CMS regulations, and identifies systemic issues that impact claims accuracy, financial performance, and member outcomes.What You'll Do
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
What You Bring
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.
Bonus Points (Preferred Qualifications)
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 eq
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