Pharmacy Operations Business Analyst (Remote)

$59,994 - $86,991/Yr

Vaya Health

Full-time - Entry Level

Remote

About the position

The Pharmacy Operations Business Analyst position at Vaya Health is a remote role that operates on US Eastern Standard Time, specifically from 8:30 AM to 5:00 PM. This position is integral to the Behavioral Health/Intellectual and Developmental Disability (BH I/DD) Tailored Plan, which adjudicates claims for behavioral health, physical health, and pharmacy services, ensuring compliance with contractual requirements. The Business Analyst will facilitate both the technical and manual aspects of the Physician Administered Drug Program (PADP) and the Outpatient Pharmacy program. This role is crucial in assisting with the review of reports and coordinating benefit change management, which aims to optimize pharmacist resources and allow the Pharmacy Director and VP of Pharmacy Services to concentrate on clinical analysis and overall plan management. Under the direct supervision of the Pharmacy Director of NC Managed Medicaid Programs, the Business Analyst will collaborate with Vaya's Information Systems Division (ISD) to support pharmacy benefits management efforts. The role involves assessing and resolving daily pharmacy operations needs, including response file reviews and managing the Lock-In Program. The Business Analyst will also be responsible for conducting weekly audits of PBM claims and encounters, managing benefits change, and compiling data for monthly reports. This position requires a proactive approach to monitor and ensure timely data exchanges between Vaya and its PBM, utilizing business judgment to assess results and escalate issues as necessary. The essential functions of the role include drafting communications for providers and members, monitoring claims for issues requiring manual intervention, and tracking key performance indicators related to PADP claims processing. The position demands excellent verbal and written communication skills, strong organizational abilities, and proficiency in Microsoft Office software. Additionally, the candidate should have a keen interest in learning various software packages related to drug information databases and medical claims processing systems.

Responsibilities

• Conduct weekly audits for PBM claims and encounters.
• Manage benefits change and the Lock-In Program.
• Gather, compile, and analyze data for monthly reports.
• Perform data entry into the care management platform.
• Draft communications for providers and members.
• Monitor and ensure timely data exchanges between Vaya and its PBM.
• Use business judgment to assess results and escalate issues as appropriate.
• Review source data for necessary updates within the medical claims system.
• Work with claims system and clinical subject matter experts to implement necessary updates.
• Track and report key performance indicators of PADP claims processing across systems.
• Monitor claims for issues that require manual intervention.
• Address other reporting and administrative needs.

Requirements

• Bachelor's degree in Biology, Chemistry, Computer Science, or other technical degree required.
• Two years of experience in a technical or business analyst role.
• A master's level degree or professional designation (MBA, MPH, etc.) can substitute for experience.
• Excellent verbal and written communication skills.
• Strong organizational skills and ability to analyze and interpret policy and procedural guidelines.
• Intermediate level proficiency in Microsoft Office software.
• Interest in learning various software packages, including drug information databases and medical claims processing systems.

Nice-to-haves

• Knowledge in processing claims for prescription drugs.
• Awareness of pharmacy data.
• Understanding of the software development life cycle (SDLC).
• Experience in developing processes for timely oversight of data processes.
• Understanding of claims editing for medical and outpatient pharmacy claims.