Pharmacy Business Analyst

InnoSoul•Denver, CO

5d•Remote

About The Position

Pharmacy Business Analyst positions are responsible for implementing system changes for the PBMS, Business Intelligence Data Management (BIDM) and Colorado Interchange (iC) related to prescription drug benefits. They will demonstrate expertise in the technical aspects of claims processing, adjudication, eligibility and enrollment and technical change projects as they relate to the PBMS, BIDM and iC. Positions will communicate system strategies with various policy and technical staff on various solutions to develop configuration changes to the system. The BAs collaborate on technical design of the systems, work with contractors to develop and review requirements and technical specification documents, and reviews test cases related to system changes.

Requirements

Database Data Analysis Novice (1-3 Years)
Operating Systems Windows 10 Novice (1-3 Years)
Healthcare/Pharmacy Benefit Manager (PBM) Healthcare/PBM claims processing and adjudication experience. Proficient (4-6 Years)
Configuration Change Management (CCM) Drafting configuration change management (CCM) documents. Proficient (4-6 Years)
Medicaid Experience processing healthcare claims for or within state Medicaid agencies. Proficient (4-6 Years)
Communication skills both verbal and written Novice (1-3 Years)
Integration planning and strategy Novice (1-3 Years)
Learning ability Novice (1-3 Years)
Process Flow Analysis Novice (1-3 Years)
Project management Novice (1-3 Years)
Proposal writing Novice (1-3 Years)
Team work Novice (1-3 Years)
MicrosoftOffice Novice (1-3 Years)

Responsibilities

Identifies, initiates and assures the quality installation of system functionality and change/enhancement projects for the prescription drug claims in the PBMS, BIDM and Colorado interchange; including all claims and capitation related system changes, pricing, benefit plans, reference codes, and interface file exchanges.
Drafts configuration change management (CCM) documents and reviews test cases on a large scale related to the PBMS reprocurement and implementation.
Coordinates with pharmacy staff and acts as the project manager for tasks relating to designing or enhancing systems, diagnosing system issues, analyzing test results, and coordinating system procedures related to pharmacy claims processing.
Arranges policy staff attendance at system requirement change reviews, system design reviews, test case reviews, and project status reviews when necessary.
Serves as the liaison between the Department, PBMS staff, Fiscal Agent staff, and other contractor staff to translate new or revised processes, and coordinates with other sections in the Department to implement system changes.
Analyzes the business need of projects by researching federal and state regulatory procedures for prescription drug claims processing, pricing and rebate.
Drafts system requirements for new and revised processes to integrate pharmacy benefits and programs into various systems and collaborates with other system analysts and vendors in the development, validation process and review of technical specifications.
Reviews test plans, technical specifications, test results and provides system documentation for new and revised processes.
Assures Medicaid Management Information System (MMIS) and BIDM system changes align with the PBMS functionality and maintains a system of checks and balances to assure that data is consistent, complete and accurate.
Works with providers and managed care organizations related to claim submission in the interchange and PBMS and works with pharmacy staff to ensure that PDL, Appendix P and Appendix X updates are properly translated into the relevant systems.
Assists with the system functions for drug rebate processing.
Coordinates testing for the PBMS, BIDM, Colorado interchange and relevant subsystems related to new or revised processes.
Researches testing topics and validates that test results meet the identified functional requirements for the change request.
Coordinates with program staff and system staff to review test results to ensure that the system functions as intended.
Analyzes test results for defect findings and defines the remediation process for the test environment while working with the system vendor to ensure that the defects are corrected, fully retested and approved for production.
Creates and documents test scenarios according to the business requirements.
Provides status reports on testing to relevant staff and vendors.
Evaluates new and existing system functionality to ensure alignment with program policy requirements and regulations.
Provides approval, disapproval or modification of design documents in consultation with other pharmacy staff.
Assesses the impact of the design document across systems by requesting system testing to evaluate effect on other system areas.
Provides support with end user testing as needed.
Examines and analyzes federal and state publications, including proposed rules and laws, to determine if changes are needed for the PBMS, BIDM or Colorado interchange systems and works with system analysts to formulate the required system change and associated test cases necessary to implement the change.
Updates the CMS required Advance Planning Document (APD) for review and approval when necessary.
Monitors and assures quality of all assigned projects with Department staff, the fiscal agent, PBMS, BIDM and other vendors to ensure that system changes meet the intent and purpose of the project requirements.
Tracks all assigned system change requests for critical and collaborative change testing needs.
Responds and provides technical support to inquiries from Department policy staff, Fiscal Agent staff, CMS staff and others related to assigned subsystems and special projects.
Assists the Office Director, Deputy Director and Pharmacy Operations Manager on ad hoc projects and assignments.
Perform other duties as assigned.