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Prescription Plan Design Escalations Analyst

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Blue Cross Blue Shield of Arizona

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Location:
United States , Phoenix

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Category:
Health and Beauty

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Contract Type:
Not provided

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Salary:

Not provided
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Job Description:

Responsible for internal and external functions that support accurate claim processing for medications.

Job Responsibility:

  • Analyze PBM prescription claim and other applicable systems for medication benefit quality and accuracy
  • Support internal and external customers with information on benefits applicable to medication claims
  • Perform, evaluate, and assist in defining and improving the quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines
  • Administer, interpret, and maintain current working knowledge of required BCBSAZ systems, procedures, forms and manuals
  • Communicate recommendations in regard to medication claim processing and benefit decisions
  • Monitor and investigate reported plan set up system issues
  • Participates in quality initiatives
  • including functions that support audits, reporting, evaluation of quality opportunities and concerns, and creation and implementation of corrective actions as requested
  • Resolve escalated member issues
  • Research & provide recommendations for accumulations issues
  • Logs all benefit setup issues on error tracking reports
  • Provide monthly updates on error resolutions and impact reports
  • Communicates issues identified within vendor system effectively to team
  • Communicates issues identified within plan setup testing or another escalated research to team
  • Strategizes solutions for issue resolution and communicates plans to team
  • Provides written documentation for desk levels
  • Provides support to other team members when necessary
  • Review plan testing documents for minimal accuracy
  • Primary liaison for Pharmacy Management for applicable benefit design questions
  • Primary SME contact for various internal departments within BCBSAZ In regard to pharmacy plan setup and design
  • Builds reporting and analyzes data for benefit recommendations to management
  • Review and determine pharmacy benefit setup upon renewal for all benefit plans
  • Build and setup all new pharmacy benefits in the pharmacy system
  • including standard patient pays
  • Submit drug code assignments to enrollment for all benefit plans Maintain pharmacy drug code matrix
  • Perform quality checks and analysis on drug code setup from other analysts
  • Review escalated plan testing questions for accuracy and make corrections as needed
  • Setup all complex pharmacy benefit plan designs
  • Setup all complex patient pays, and any other design element related to complex pharmacy benefits
  • Works with Pharmacy Management Leadership team to identify project prioritization
  • Allocates resources to ensure required work is accomplished within defined time frames
  • Assigns Tasks to Analysts and Specialists as needed
  • Properly track all pharmacy benefit issues & concerns
  • Perform all other duties as assigned

Requirements:

  • Experience in pharmacy or medical field (Level 1 – 3 years
  • Levels 2 and 3 – 5 years
  • Level 4 – 6 years)
  • Experience in prescription benefit administration (Level 1 – 1 year
  • Level 2 - 3 years
  • Level 3 – 5 years
  • Level 4 – 6 years)
  • Experience working in vendor applications (rebate, web tools, formulary tools) (Level 2 – 1 year
  • Level 3 – 2 years
  • Level 4 – 5 years)
  • 5 years’ experience in progressive responsibility with allocation of resources and participating in management of complex projects (Level 4)
  • High-School Diploma or GED
  • Intermediate PC proficiency with word processing, spreadsheets, and claims and imaging software (Level 1)
  • Intermediate skill using office equipment, including copiers, fax machines, scanners and telephones (all Levels)
  • Advanced PC proficiency, including spreadsheet and vendor application software (Levels 2 and 3)
  • Take initiative
  • Establish and maintain working relationships in a collaborative team environment
  • Flexibility in prioritization of workflow
  • Compose a variety of business correspondence
  • Make use of employees' skills and abilities to deliver business objectives
  • Use available information to focus the team's activities and identify priorities

Nice to have:

  • Experience with a pharmacy benefit management or prescription claim administration (Levels 1 and 2 – 3 years
  • Level 3 – 5 years
  • Level 4 – 6 years)
  • Experience with the current BCBSAZ PBM system (Levels 1 and 2 – 1 year
  • Level 3 – 2 years
  • Level 4 – 6 years)
  • Experience with BCBSAZ claims software / systems (Level 2 – 1 year
  • Level 3 – 2 years
  • Level 4 – 6 years)
  • Demonstrated experience handling confidential information (Level 1 – 2 years
  • Level 2 – 3 years
  • Level 3 – 4 years
  • Level 4 – 6 years)
  • Demonstrated experience handling vendor system coding and analytic functions (Level 3 – 5 years
  • Level 4 – 6 years)
  • 5 years’ demonstrated experience handling complex projects and allocation of resources (Level 4)
  • Associate’s degree in general field of study
  • Advanced PC proficiency with word processing, spreadsheets, and claims and imaging software (Levels 2 – 3)
  • Effective interpersonal communication
  • Multicultural sensitivity
  • Claim system experience with pharmacy vendor software and/or systems (Levels 2 – 3)

Additional Information:

Job Posted:
March 04, 2026

Employment Type:
Fulltime
Work Type:
Hybrid work
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