Prescription Plan Design Escalations Analyst Job at Blue Cross Blue Shield of Arizona (Phoenix)

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)

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Prescription Plan Design Escalations Analyst

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