Senior Data Analyst, Quality Review - Medicare Pharmacy Claims Part D & Part B)

Blue Cross and Blue Shield of North Carolina • Remote Flex - North Carolina, SC

9d • $89,174 - $142,679 • Hybrid

About The Position

We're hiring a Senior Data Analyst to join the Government Pharmacy Programs Department! The Senior Data Analyst, Quality Review – Medicare Pharmacy Claims is responsible for ensuring accurate, compliant adjudication of Medicare Part D and Medicare Part B pharmacy claims. This role performs detailed quality oversight, validates benefit and pricing logic, ensures adherence to CMS regulations, and identifies systemic issues that impact claims accuracy, financial performance, and member outcomes.

Requirements

• Bachelor's degree or advanced degree (where required)
• 5+ years of experience in related field. In lieu of degree, 7+ years of experience in related field.
• Advanced analytical skills with experience performing claim analyses and error trending
• Proficiency in Excel
• Strong documentation, communication, and cross‑functional collaboration skills

Nice To Haves

• 5+ years of Medicare pharmacy claims, PBM, or managed care experience
• Direct experience with Medicare quality review, compliance, auditing, or PDE support strongly preferred
• Strong expertise in Medicare Part D pharmacy claims adjudication, including PDE requirements and CMS benefit rules
• Working knowledge of Medicare Part B drug billing, HCPCS, and pharmacy‑to‑medical claim integration
• Solid understanding of CMS regulations, including: Cost‑sharing and benefit phase logic, LIS and subsidy calculations, Formulary management and UM edits (PA, ST, QL)
• experience with prescription adjudication systems and Medicare reporting tools preferred
• Pharmacy Technician certification or equivalent pharmacy background is a plus

Responsibilities

• Perform comprehensive quality reviews of Medicare Part D and Part B pharmacy claims, including retail, mail order, LTC, specialty, and medical‑benefit drug claims
• Validate accurate application of: Medicare Part D phases (Deductible, Initial Coverage, Catastrophic), Low‑Income Subsidy (LIS) cost‑sharing, MOOP accumulations, PDE data elements and claim submission logic, MAC list pricing, Pharmacy discounts and dispensing fee accuracy by pharmacy type
• Identify irregular prescribing and/or dispensing patterns for investigation and referral to PBM, internal audit and SIU teams
• Review Part B drug claims for correct HCPCS coding, units of service, allowable charges, and coordination with medical claims
• Identify claim adjudication errors related to pricing, benefit configuration, formulary status, utilization management edits, and CMS rules
• Partner with Compliance to ensure claims accuracy consistent with CMS guidance, Medicare manuals, and plan sponsor requirements
• Support internal and external audits (CMS program audits, CTM, PDE validation, RADV support activities) by identifying findings, impact analysis, remediation documentation, and Corrective Action Plans
• Conduct root cause analysis on quality findings; partner with Compliance, IT, operations, and PBM teams to implement corrective actions
• Develop and maintain quality metrics, dashboards, and trend reports related to Medicare claims accuracy and risk
• Serve as a subject matter expert for Medicare pharmacy claims processing
• Provide guidance and mentorship to peers and colleagues, and contribute to Medicare‑specific quality standards, SOPs, and training materials

Benefits

• Medical, dental, and vision coverage along with numerous health and wellness programs
• Parental leave and support plus adoption and surrogacy assistance
• Career development programs and tuition reimbursement for continued education
• 401k match

What This Job Offers

• Job Type: Full-time
• Career Level: Senior