The Quality Excellence Analyst II will leverage knowledge to assist in anlayzing plan design set up for accuracy. This position will utilize system expertise, client documentation, adjudication rules, Quality Excellence processes and prodedures to effectively identify coding errors. This position will also be responsible for error tracking and resolution.
- Must be proficient in all of the essential functions of a Quality Excellence Analyst I.
- Must be knowledgeable of all adjudication platforms used by the Company.
- Work with cross functional teams to suggest, implement and document process improvements.
- Responsible for meeting turnaround times, quality measurements and performance guarantees.
- Acts as project lead for corporate initiatives where quality standards are needed.
- Follows all policies and procedures relating to job function.
- Analyze client documentation against system set up to identify defects.
- Utilize both manual and automated testing processes to determine accuracy of benefit coding.
- Reporting defects identified during testing to appropriate departments consistently until resolved.
- Effective in the utilization in various aspects of Quality Excellence including; software, tools, procedures, best practices etc.
- Cross train individuals in client nuances, pharmacy pricing components, pharmacy networks, clinical formulary edits, system set up and limitations, hierarchies and trouble shooting.
- Performs other duties as assigned to meet corporate initiatives.
- Travel as needed.
Candidates must possess a strong working knowledge of the RxClaim adjudication platform. Must be proficient in the Microsoft Office Suite of systems (Word, Excel, PowerPoint, Access). Candidate must possess strong communication skills, both written and verbal as well as good presentation presence. Ability to develop and maintain strong relationships with internal partners and oversee development of a professional team. This individual must be abile to adapt to a changing work environment including scheduling flexibility. Ability to define problems by collecting data, establishing facts and drawing valid conclusions by utilizing a systematic approach.
High school diploma required. College level education is a plus.
- Minimum of 2 years of Quality and or RxClaim coding experience.
- Minimum of 3 years experience in the Pharmacy Benefit Management (PBM) industry.
- Knowledgable in prescription benefit set up and adjudication ruls in AS400/RxClaim platform.
- Must posses strong organizational and analytical skills to review claims data and audit against plan specifications.
- Must be able to meet tight deadlines in a fast-paced environment.
- Experience in automation and query tools required.
- Experience with Medicare Part D set up a plus.
Catamaran - 2 years ago
Catamaran offers a true alternative to the status quo in pharmacy benefit management. You donâ€™t have to choose between...