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JOB TITLE: Pharmacy Benefit Analyst (PBA) – Part-time
The Pharmacy Benefit Analyst will be responsible for the oversight of design, development, testing, deployment, and documentation of plan/benefit design for each pharmacy benefit management (PBM) contract This staff person will build the plan design within the claim adjudication system using knowledge of benefit design, NCPDP data elements, and pharmacy processes. The Pharmacy Benefit Analyst will also be a resource for pharmacy technicians responding to issues related to plan/benefit design. Additionally, the PBA will collaborate and work with the Clinical Services Department for the implementation, set up and maintenance of clinical plan/benefit design requirements resulting in assured adherence to desired formulary goals for Ramsell clients.
The Pharmacy Benefit Analyst is responsible for serving as a liaison between assigned clients, client team members, claims adjudication vendor and operational staff to provide technical support for all pharmacy benefit clients. This individual will collaborate with internal and external stakeholders to create solutions that integrate technology, information, and business processes and will match appropriate technology solutions to business needs. They will assist with identifying, planning, implementing, and maintaining available business system solutions that support client operational needs and will maintain a current understanding of client file layouts, relationships, logic and how they operate. They will provide technical consultation to the client team and related internal stakeholders. As an integral team member, they will write detailed descriptions of client needs, program functions, and steps required to develop or modify business systems.
- Builds and maintains plan/benefit design rules and limitations to include:
- Implementation of adjudication rules
- Implementation of clinical rules for prior authorization and formulary management
- Application of pharmacy rates and changes
- Claim testing to ensure accurate claim adjudication program guidelines.
- Client management
- Plan/group management
- Acts as liaison between client and internal stakeholders, and claims adjudication vendor to coordinate receipt of required information for claims adjudication system set up, reporting and claim adjudication process. This includes the following tasks:
- Attends implementation meetings with claims adjudication vendor to discuss technical requirements and protocols.
- Maintains published timelines for receiving and processing client data and communicates targets to staff and clients. Coordinates with client to ensure the timely receipt and processing of scheduled data.
- Develops, maintains, and formats client data fields and reporting requirements
- Analyzes reports to research and resolve discrepancies, errors, and problems.
- Troubleshoots issues from client and internal departments that interrelate with claims data submission and processing.
- Serves as liaison between client technical team and claims adjudication vendor for both routine work and special projects.
- Serves as a general PBM technical resource to the account management team.
- Analyzes claims data and coordinates with business reporting teams.
- Manages multiple projects to achieve timely and effective completion.
- Evaluates processed claims, identifies errors and makes adjustments accordingly.
- Creates and maintains plan/benefit design documentation for all PBM contracts/solutions.
- Provides training and oversight to PBA representatives.
- Works collaboratively with all Ramsell Business Services’ Team leads to ensure effective communication.
- Acts as a resource for pharmacy technician staff in support of the claims adjudication process (plan/benefit set up) and pharmacy help desk.
- Interacts with Ramsell IT to coordinate plan/benefit design changes.
- Recommends new and enhanced system logic to support plan/benefit design.
- Makes recommendations to streamline the work processes, create efficiency and assist with updates.
- Researches plan/benefit design options and requirements as required.
- Provides clerical and/or technical support to President, such as gathering data and information, preparing templates, and reports.
- Provides optimum customer service.
- Performs all functions relating to pharmacy provider services.
- Prior authorization (PA), claims authorization (CA) and claims processing based on program guidelines.
- Serves as a liaison between program members and pharmacy providers.
- Uses professional knowledge in PA processing, utilizing pharmacy technician skills in dosage calculations, client compliance, and knowledge of medications (trade, generic).
- Uses institution’s online system to validate and follow-up on claims adjustments, suspensions and Prior Authorizations (PA)
- Performs other duties as assigned.
- Continued education in the areas of written and verbal communication skills and computer skills.
- Excellent written and verbal communication skills.
- Demonstrated positive interpersonal skills.
- Strong organizational skills, detail oriented.
- Ability to work independently as well as with team members.
- Must be creative and resourceful, self-starter, highly motivated, critical thinker.
- Ability to provide client consultation and facilitate client meetings over the phone and face-to-face.
- Experience working with internal and external client personnel.
- Advanced use of Microsoft Office Products (ex. Excel skills: V-lookups, formulas, ability to create, edit, and run reports).
- Experience using Microsoft Project and Visio a plus.
- Typing: 45 wpm.
- 10-key by touch.
- A.A. degree or higher desired.
- Licensed Pharmacy Technician and/or CPhT License.
- Experience in use of prescription benefit claims adjudication system for plan/benefit design, RxClaim experience preferred.
- Minimum of two years’ experience as a pharmacy technician for a Pharmacy Benefit Management company or related healthcare organization.
- Retail Pharmacy experience.
- Program/project management experience preferred.
- Predominately sedentary office position with high frequency of keyboarding/computer work required (80% to 100%) of the workday.
- Close vision required.
- Limited - Periodic
Please email your resume to: email@example.com