Employment Type:

Full time

Shift:

Day Shift

Description:

Why MediGold?

               

MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. We’re dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage. We rely on talented colleagues in a wide variety of professional roles including information technology, financial analysis, audit, provider relations and more.

Position Purpose:

Pharmacy/Clinical Service Data Analyst is responsible for data collection, data verification and data reporting in compliance with the Plan requirements and CMS guidelines. Supports the Plan as a result of internal or external business needs in producing scheduled and ad hoc reports as needed and produces data in an objective and meaningful way.

What you'll do:

Develop and run detailed ad hoc reports for pharmacy claims analysis and review.

· Coordinate and work with PBM and internal departments related to the pharmacy audit requests.

· Trend and identify inappropriate pharmacy utilization to ensure compliance with all federal and state regulations on pharmacy, member and providers fraud, waste and abuse

· Oversee and audit the pharmaceutical contracts in regard to appropriate loading, executing, and compliance with the contract.

· Conduct reconciliation efforts and reviews as needed on providers, pharmacies and members.

· Trend analysis of pharmacy utilization for formulary compliance and contract compliance.

· Responsible for validating and reporting CMS required Part D data reporting.

· Responsible for CMS compliance requirements with regard to written communications to Members and Providers.

· Responsible for plan-to-plan transfer reconciliation including payment and receivable tracking.

· Responsible for PDE reconciliation and error resolution, in coordination with other Plan departments.

· Responsible for FIR transaction processing for the proper communication and consideration of out-of-pocket balances.

· Responsible for formulary review and production of supporting Member and Provider materials, including, but not limited to, printed Formulary, online formulary and updates, Drug Pricing application and annual change communications.

· Trends, reports and remedies any identified operational issues or concerns with respect to the Plan's delegated arrangement with PBM.

· Responsible for the review, approval and coordination of Member Explanation of Benefits.

· Responsible for daily review of rejected claims process.

· Participant in strategy planning sessions specific to Plan's drug plan offering(s).

· Responsible for oversight of clinical management programs such as Medication Adherence, Drug and Safety Monitoring, Medication Therapy Management, Quality Reporting, etc.

· Responsible for assisting the Plan with data collection and audit activities to ensure internal and external compliance with CMS.

· Performs routine audit activity as part of the Plan's Compliance program.

What we're looking for:

Education: Bachelor’s Degree or equivalent experience

• · License / Certification: Certified Pharmacy Technician preferred

Experience:

• o Minimum 3 years of insurance or healthcare experience with a preference for Medicare Advantage Part D actual experience preferred.
• o A minimum two years of experience in health care data and analysis preferred.

Effective Communication Skills

Excellent communication, critical thinking, analytical and organizational skills. Knowledge of drug names pharmaceutical industry terminology, program compliance and diagnosis coding (ICD9 and ICD10) required.

Experience with relational databases, data collection, reporting and query tools; successfully extracts, manipulations and reports data for customer preferred.

Technically sophisticated with relational database concepts and applications, analytic data development (statistics) and decision support tools preferred.

Strong operational knowledge of managed care business processes preferred

Position Highlights and Benefits:

• Competitive compensation and benefits packages including medical, dental, and vision with coverage starting on day one.
• Retirement savings account with employer match starting on day one.
• Generous paid time off programs.
• Employee recognition programs.
• Tuition/professional development reimbursement.
• Relocation assistance (geographic and position restrictions apply).
• Discounted tuition and