Pharmacy Operations Business Analyst

Moda Health•Portland, OR

2d•Hybrid

About The Position

Moda Health is seeking a Pharmacy Operations Business Analyst for a full-time, hybrid position based in Portland. This role serves as the technical and analytical resource for Pharmacy Operations, supporting the design, validation, monitoring, and continuous improvement of pharmacy operational processes, systems, and vendor performance. The analyst will be responsible for analyzing pharmacy claims, validating benefit and formulary configuration, supporting operational implementations, developing reporting and monitoring tools, and identifying opportunities to improve operational efficiency, accuracy, and regulatory compliance. This position works closely with various departments including Pharmacy Operations leadership, Information Technology, Account Management, Compliance, vendor partners, and other business stakeholders. The analyst will perform complex operational analysis, root cause investigations, data validation, configuration testing, and system support across Commercial, Exchange, Medicare, and Medicaid lines of business. This role is critical for ensuring the accuracy of pharmacy benefit administration, supporting CMS reporting and audit activities, monitoring operational performance, and implementing sustainable controls to improve quality and reduce operational risk.

Requirements

Bachelor's degree or equivalent combination of education and relevant experience in healthcare administration, business administration, pharmacy, information systems, or a related field.
Five or more years of professional experience in pharmacy operations, pharmacy benefit management, health plan administration, or a closely related healthcare environment.
Demonstrated knowledge of pharmacy benefit administration, pharmacy claims processing, benefit configuration, formulary management, prior authorization operations, and operational workflows.
Experience analyzing complex operational data, pharmacy claims, system functionality, and business processes to identify issues, recommend solutions, and improve operational performance.
Experience developing business requirements, coordinating system testing, validating system enhancements, and supporting operational implementations.
Demonstrated knowledge of Commercial, Exchange, Medicare, and Medicaid pharmacy operations and applicable regulatory environments.
Strong analytical, problem-solving, and root cause investigation skills with the ability to interpret complex operational and claims data.
Demonstrated ability to manage multiple priorities, work independently, and successfully support concurrent operational initiatives.
Strong written, verbal, presentation, and interpersonal communication skills, with the ability to communicate effectively with both business and technical stakeholders.
Proficiency with Microsoft Office applications, particularly Excel, and experience working with pharmacy operational systems, reporting tools, or healthcare data platforms.
Demonstrated ability to develop documentation, operational procedures, business requirements, and testing documentation.

Nice To Haves

Experience supporting Medicare Part D operations, CMS reporting, audit activities, or regulatory compliance initiatives.
Experience with PBM claims adjudication platforms, pharmacy benefit configuration, formulary management systems, or prior authorization platforms.
Experience performing pharmacy claims analysis, configuration validation, benefit testing, or operational monitoring.
Experience developing operational reporting, dashboards, data validation processes, or performance monitoring tools using SQL, Power BI, Tableau, or comparable reporting tools.
Experience supporting vendor oversight, system implementations, operational readiness activities, or cross-functional process improvement initiatives.
Experience conducting root cause investigations and developing operational controls to improve quality, compliance and operational performance.

Responsibilities

Analyze pharmacy claims, operational data, and system activity to identify trends, operational issues, and opportunities for improvement.
Conduct root cause investigations for claims discrepancies, operational issues, configuration concerns, and vendor-related incidents.
Develop operational reporting, dashboards, and monitoring tools to measure performance, identify emerging risks, and support operational decision-making.
Perform data validation and operational monitoring to ensure the accuracy and integrity of pharmacy operations across Commercial, Exchange, Medicare, and Medicaid lines of business.
Validate pharmacy benefit, formulary, network, and prior authorization configuration to ensure accurate claims adjudication and operational performance.
Coordinate and perform benefit, formulary, and system testing supporting new client implementations, regulatory changes, operational enhancements, and vendor releases.
Develop business requirements, test plans, test scenarios, and validation documentation while tracking issues through resolution.
Partner with internal stakeholders and vendor partners to evaluate system enhancements, validate implementation outcomes, and recommend operational improvements.
Support Medicare Part D operational activities, including CMS reporting support, operational monitoring, audit readiness, and regulatory compliance initiatives.
Assist with internal and external audit activities through data validation, issue analysis, documentation, and corrective action support.
Monitor vendor operational performance, validate deliverables, investigate discrepancies, and coordinate issue resolution with vendor partners.
Develop and maintain operational controls that improve data integrity, regulatory compliance, and vendor accountability.
Identify opportunities to improve pharmacy operational processes through automation, standardization, enhanced reporting, and monitoring.
Develop and maintain business requirements, operational procedures, process documentation, reporting specifications, and technical documentation supporting pharmacy operations.
Provide analytical support for new client implementations, operational projects, system enhancements, and strategic initiatives.
Collaborate with Pharmacy Operations, Clinical Pharmacy, Account Management, Information Technology, Compliance, Customer Service, and vendor partners to support operational excellence and continuous improvement.