Principal PBM Operations Analyst

Blue Cross Blue Shield of Minnesota•Eagan, MN

1d•Hybrid

About The Position

About Blue Cross and Blue Shield of Minnesota At Blue Cross and Blue Shield of Minnesota, we are committed to paving the way for everyone to achieve their healthiest life. We are looking for dedicated and motivated individuals who share our vision of transforming healthcare. As a Blue Cross associate, you are joining a culture that is built on values of succeeding together, finding a better way, and doing the right thing. If you are ready to make a difference, join us. The Impact You Will Have The Principal PBM Operations Analyst will focus on establishing and refining operational processes related to CMS and State requirements for Medicare products. This position will develop an oversight structure of the Pharmacy Benefit Manager(s) (PBM) , departmental and key stakeholder activities. This oversight structure will include the establishment of KPI's and program dashboards to measure performance.

Requirements

10+ years of professional experience in pharmacy at a health plan or PBM.
7+ years of project management/relationship management experience required, preferably in the pharmacy or healthcare industry preferred.
5+ years of experience in triaging and resolving inquiries associated to claims and benefits.
7+ years of experience working Medicare Part D
5+ years of management experience (employees and/or vendor services)
High school diploma (or equivalency) and legal authorization to work in the U.S.

Nice To Haves

Previous experience in pharmacy technician role, with or without certification
PBM experience preferred
Bachelor’s degree or equivalent experience

Responsibilities

Core responsibilities will involve project management, operational management and oversight of the Pharmacy Benefit Manager(s) (PBM).
Build and manage dashboards for PBM oversight reporting including volume trending/analysis and quality review outcomes of key performance indicators including claims, coverage decisions and appeals, formulary, and networks.
Present dashboards/reporting to Compliance Officer and Leadership, as applicable.
Continuously assess risk and evaluate oversight program for improvement opportunities.
Define and document oversight processes, policies, and procedures for delegated pharmacy functions including those intended to identify risk and internal controls.
Develop enhancement strategies to existing process and technology capabilities.
Manage enhancement-related projects with cross-functional teams including IT, Pharmacy, Operations, Compliance, etc.
Develop and manage project plans for PBM, internal stakeholder, or external vendor initiatives to ensure an accurate, timely and highly coordinated implementation.
Oversee PBM and Pharmacy Analyst work of Medicare PBM operational components.
Manage, and oversee Medicare Part D requirements and corresponding operational processes. Including, but not limited to: payment integrity - PDE/Encounter Data, FIR's, NX Transactions, and Coordination of Benefits, regulatory – implementation of guidance, audit management, regulatory reporting, CMS and DHS interactions, coverage decisions and appeals, claims. benefits, formulary/PDL, networks and materials
Establish PBM KPIs and Program dashboards to manage and measure outcomes related to performance guarantees.
Draft and maintain administrative pharmacy policies related to core job responsibilities.
Collaboratively work with internal and external partners, clients, and vendors.
Oversee intake, management, and resolution of inquiries, issues, or requests for information received from members, groups, Clients, CMS/DHS and/or any other channel.
This position does not have direct supervisory responsibilities but will oversee Analyst work product.