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Medicare Part D Claims Analyst

This position is responsible for overseeing the accurate adjudication and administration of Part D claims and formulary administration.

Essential Functions

• Test the accuracy of the formulary administration policy, including transition, by reviewing daily transition monitoring reports, conducting routine audits on formulary rejections and performing trend analysis.
• Make outreach to members and pharmacies to resolve claims that reject inappropriately.
• Facilitate review of the processes that support retro-active enrollment changes, changes in LICs status, and member notifications
• Report trends in claims rejections and potential areas of non-compliance to Compliance officer.
• Ability to identify member impact by issue.
• Initiate client communications related to trended issues.
• Assist in investigating and correcting operational issues that result in denied claims.
• Develops, implements, and maintains an audit tracking and documentation system.

Qualifications

• Intermediate level of proficiency in MS Excel (writing formulas, filtering and working with large data sets)
• 2+ years of data and complex ad hoc analysis experience
• Deep Medicare part D claims experience

Education

• Pharmacy Tech License preferred

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