Pharmacy Quality Analyst
About The Position
Under the direction of the VP of Health Services, the Pharmacy Quality Analyst is responsible for monitoring, analyzing, auditing, and improving pharmacy-related operational performance across Prominence Health and its Pharmacy Benefit Manager (PBM) partner. This position serves as a key resource for identifying operational breakdowns, compliance risks, service gaps, and process inefficiencies that impact members, providers, pharmacies and brokers. The Pharmacy Quality Analyst utilizes data analysis, operational audits, CMS compliance reviews, performance monitoring, and root cause methodologies to identify trends, investigate issues, and recommend sustainable corrective actions. The role supports operational excellence by ensuring pharmacy services, claim processing, prior authorization functions, formulary administration, customer service, and other PBM-related activities are delivered accurately, efficiently, and in compliance with CMS, Medicare Advantage, and contractual requirements. This position works closely with Pharmacy, Operations, Health Services, Compliance, Customer Service, and PBM partners to support continuous improvement initiatives that enhance regulatory compliance, operational effectiveness, and overall customer experience.
Requirements
- Bachelor’s degree in healthcare administration, Pharmacy, Business Administration, Public Health, Compliance, Data Analytics, or related field.
- 3 or more years of operational experience in a retail or hospital pharmacy, PBM, managed care, or related healthcare organization
- Knowledge of CMS Part D regulations, Medicare Advantage requirements, and audit methodologies
- Working understanding of PBM operations, pharmacy claims adjudication, prior authorization processes, formulary administration, and member service operations.
- Proficient computer skills: Health Plan Management System (HPMS), Smartsheet, Sharepoint, Microsoft Office (Word, Excel, PowerPoint), and database software.
- Demonstrated ability to apply knowledge to recognize the existence of problems or potential problems and identify additional research to be undertaken or assistance in the following areas: internal audit standards, procedures and techniques, management principles and deviations from ethical business practices, and fundamentals of business management.
- Demonstrated ability to research, analyze and interpret state/federal regulations related to health insurance and healthcare.
- Demonstrated ability to design and develop reports, documents and spreadsheets.
- Demonstrated ability to communicate verbally and with technical writing in a way that effectively conveys project background, objectives, activities, evaluations, conclusions, and recommendations.
- Decisive and exercises good judgment under pressure.
- Demonstrated skills in critical thinking, problem solving, and the analysis, interpretation and evaluation of complex information.
- Demonstrated ability to maintain effective collaborative working relationships with staff.
- Demonstrated ability to work independently with minimal supervision.
- Resourceful, detail-oriented, and able to assimilate and analyze a wide variety of information, often working under deadline pressure with a variety of levels of staff.
- Simultaneous action at varying stages—initiation, follow through, and completion—on a number of different projects.
- Strict adherence of rules and regulations for confidentiality and compliance.
Nice To Haves
- Current and valid state licensure as a pharmacy technician is preferred.
Responsibilities
- Monitoring pharmacy-related operational performance
- Analyzing pharmacy-related operational performance
- Auditing pharmacy-related operational performance
- Improving pharmacy-related operational performance
- Identifying operational breakdowns
- Identifying compliance risks
- Identifying service gaps
- Identifying process inefficiencies
- Utilizing data analysis for trends and issues
- Conducting operational audits
- Performing CMS compliance reviews
- Monitoring performance
- Applying root cause methodologies
- Recommending sustainable corrective actions
- Ensuring pharmacy services are delivered accurately, efficiently, and in compliance
- Ensuring claim processing is delivered accurately, efficiently, and in compliance
- Ensuring prior authorization functions are delivered accurately, efficiently, and in compliance
- Ensuring formulary administration is delivered accurately, efficiently, and in compliance
- Ensuring customer service is delivered accurately, efficiently, and in compliance
- Ensuring other PBM-related activities are delivered accurately, efficiently, and in compliance
- Supporting continuous improvement initiatives
Benefits
- Loan Forgiveness Program
- Challenging and rewarding work environment
- Competitive Compensation & Generous Paid Time Off
- Excellent Medical, Dental, Vision and Prescription Drug Plans
- 401(K) with company match and discounted stock plan
- SoFi Student Loan Refinancing Program
- Career development opportunities within UHS and its 300+ Subsidiaries!
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
