Icon hamburger
US
What job do you want?
Apply to this job.
Think you're the perfect candidate?
Apply Now
Thumsup

You’re being taken to an external site to apply.

Enter your email below to receive job recommendations for similar positions.
Mfx145702hn67z7ngrv

Government Programs Pharmacy Performance Analyst

EmblemHealth New York Full-Time
Apply Now
Ensure timely and compliant pharmacy operations for Medicare, Medicaid and Exchanges lines of business for both EmblemHealth and ConnectiCare.  Review federal and state guidance and determine next steps for the organization to maintain or achieve compliance.  Define business requirements to ensure compliance with CMS and state guidance.  Monitor operational processes for compliance including IRE submissions, claim processing and managing the appropriate payer within the Medicare program.

Responsibilities:

  • Lead the CMS application submission process annually; this is a high impact and important process with the potential to help or hinder our bottom line results.
  • Lead the assessment of appropriate payment by part D or other for ESRD, Hospice and Non-Renal Transplant members and claims.
  • Collaborate with the Pharmacy Operations team to deliver a successful Annual Enrollment Period. 
  • Collaborate with the Enrollment team to ensure appropriate data is passed to ESI and claims adjudicated compliantly.  Work closely with PDE team to correct errors.  
  • Lead the development of annual Medicare marketing materials for Pharmacy including writing, submitting for approval, testing and validating in production (about 60 separate and unique materials).
  • Research, interpret, and communicate with appropriate parties in order to facilitate understanding of ESI Field Alerts, which often represent issues and change; define actions to be taken; provide recommendations and lead the implementation of required actions, disclosures and communication; follow through to ensure resolution.
  • Define dashboard metrics required; collaborate with reporting team to deliver; measure regularly; assess results and build the strategy for improvement, then execute against that strategy.
  • Oversee the Troop Balance Transfer process ensuring appropriate processing in the required timeframe. 
  • Participate in 1/1 implementation ensuring all Medicaid and Medicare requirements are tested and successfully implemented.
  • Partner with compliance on issues and changes when appropriate.  
  • Prepare supporting statements for CMS disclosure.
  • Provide technical and subject matter expertise support to other areas as needed (Quality, Safety, MTM, etc.)
  • Perform independent research to maintain industry level knowledge in order to proactively address current and forthcoming changes in the healthcare environment.
  • Other duties as assigned.
Qualifications:

  • Bachelor’s degree required, advanced degree preferred
  • 4 – 6 years of relevant work experience required
  • 2 – 3 years specific healthcare related experience, preferably in a Government Programs Healthcare organization required
  • Working knowledge of Medicare and/or Medicaid regulations, processes, and structure required
  • Knowledge of Federal and State (NY) pharmacy regulations required
  • Strong communication skills (verbal, written, presentation required
  • Excellent critical thinking and problem solving skills required
  • Ability to collaborate cross functionally and to challenge the status quo required
  • Proven ability to analyze data, identify trends, calculate impact,  and synthesize that data into actionable information required
  • Ability to lead and develop others required

Recommended skills

Medicaid
Claims
Medicare
Complex Problem Solving
Hospice
Critical Thinking
Apply to this job.
Think you're the perfect candidate?
Apply Now

Help us improve CareerBuilder by providing feedback about this job: Report this job

Report this Job

Once a job has been reported, we will investigate it further. If you require a response, submit your question or concern to our Trust and Site Security Team

Job ID: 190KD

CAREERBUILDER TIP

For your privacy and protection, when applying to a job online, never give your social security number to a prospective employer, provide credit card or bank account information, or perform any sort of monetary transaction. Learn more.

By applying to a job using CareerBuilder you are agreeing to comply with and be subject to the CareerBuilder Terms and Conditions for use of our website. To use our website, you must agree with the Terms and Conditions and both meet and comply with their provisions.

EmblemHealth is
a local, neighborhood health plan that has served the New York City area and
surrounding communities for more than 75 years. That’s the kind of experience
that makes us unique. We’re proud to be one of the nation’s largest
not-for-profit health plans, serving 3.1 million people who live and work
across the New York tristate area.

View the full profile