Senior Business Analyst - Medicare (Hybrid)

CareFirst•Baltimore, MD

2d•Hybrid

About The Position

The Senior Business Analyst supports critical Medicare pharmacy business through advanced data analysis, reporting, and operational PBM oversight. This role interprets complex data to develop reports and presentations, ensures compliance with contractual and regulatory requirements, and supports quality and performance objectives across pharmacy operations.

Requirements

Bachelor's Degree in Business, Information Technology, Computer Science or related field OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
5 years progressive experience in business analysis, systems analysis, testing or other analytical experience.
High-level of knowledge and understanding of business products and services.
Microsoft Office applications usage.
Excellent communication skills both written and verbal.
Ability to analyze, organize, and prioritize work while meeting multiple deadlines.
Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.
Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Must be eligible to work in the U.S. without Sponsorship

Nice To Haves

Demonstrated ability to deliver high quality, effective deliverables on-time and be a significant contributor to the development of cost-effective solutions.
Proven understanding of business analysis core competencies
Certified Pharmacy Technician
Experience at a health plan or PBM.
Knowledge of CMS guidance and regulations.
Experience with pharmacy claims processing systems.

Responsibilities

Analyze pharmacy operational data and claims activity to identify trends, risks, and improvement opportunities.
Monitor claims processing and review pharmacy benefit coding for accuracy and compliance.
Perform prescription drug event (PDE) review, correction, and retraction activities.
Review and analyze monthly, quarterly, and annual data related to coverage determinations, redeterminations, and grievances.
Track, document, and trend Medicare and PBM-related issues to support compliance, audit readiness, and corrective action activities.
Participate in internal and external audits and third-party reviews, including formulary administration, improper payment, and Acumen reporting.
Prepare and submit routine and ad hoc Medicare KPI reports, including PBM performance and compliance tracking.
Provide analytical support and recommendations to pharmacy leadership to inform operational and strategic decisions.
Monitor member and provider communications for accuracy, timeliness, and regulatory compliance, including letters, explanations of benefits, and website content.
Coordinate with internal and external stakeholders to ensure PBM activities align with pharmacy operations and member experience expectations.
Serve as a point of contact for vendor performance oversight and issue resolution.
Support quality initiatives through provider and member outreach, participation in committees, and support of member events.
Conduct process analysis and contribute to studies aimed at improving efficiency, quality, and compliance.
Adapt to shifting priorities and manage multiple concurrent initiatives, providing operational support as needed.