As a Medicare Financial Operations Analyst I, you will be responsible for executing processes for Medicare Part D products including Prescription Drug Events (PDE), Plan Finder files, Claims Reprocessing, Claims Adjustments and Monitoring and Oversight and also Medicaid encounters. You will be asked to conduct investigations and resolve complex issues. In this role, you’ll need to have strong analytical and communication skills. You should bring an inquisitive mind and be relentless in your search for answers and solutions to complex tasks. You will benefit from an ability to quickly grasp new cases and acquire platform knowledge through independent study, as well as interaction with other team members. The ability to discuss technical logic, awareness of when to be more or less detailed, and assurance evoked through an extensive understanding of our solutions and technology is essential.
The fundamentals for the job
- In this role, you will be the in-house Medicare go-to whiz on Medicare Part D products and Medicaid Encounters. This includes the related analysis, controls and
- It is expected you will have a deep understanding of PDE, Plan Finder and Encounters:
- Master CMS regulation regarding PDE and Plan Finder
- Be proficient calculating PDEs
- Can analyze and resolve PDE errors. This includes identifying situations where reprocessing and adjustments are required and then executing those procedures
- Perform monitoring and oversight of PDEs to ensure accuracy and compliance with regulations
- Can resolve Acumen incidents related to PDEs
- Understand and execute the quality assurance checks on Plan Finder files
- Can analyze pharmacy network, formulary and pricing changes on the PBM industry and how those affect the Plan Finder data submitted to CMS
- Can analyze and cross reference Plan Finder and PDE data and its importance in the calculation of CMS Star Rating program metrics
- Can pinpoint issues on the benefit configuration and POS adjudication to alert the business on possible impact to Plan Finder submission. Should be able to document
finding and provide possible solutions
- Can understand and explain pricing hierarchy terms like AWP, WAC, discount percentages, MAC, lower of rules, etc.
- Have a reasonable understanding of pharmacy network terms like preferred, non-preferred, mail and LTC networks. Understand the concept of Out of network and the
impact of those terms in the Plan Finder Pharmacy File
- Can understand and explain general drug terminology like drug hierarchy. Drug indicators like brand/generic, multi-source code, repacks, DESI codes, etc. Should
understand how those impact the Plan Finder drug file.
- Familiar with the data elements on encounter transactions.
- Can adjust to different variance on the process depending State specific regulation.
- Keep up to date on CMS guidance related to Medicare Part D products and Medicaid Encounters. It is expected that you will also understand the guidance as well.
Additionally, it is vital for you to reference guidance when analyzing and resolving issues.
- While conducting all activities, be able to identify and proactively suggest any margin for opportunities/risks.
- Assist in the documentation of business requirements for the Medicare Financial Operations modules enhancements.
Americans are spending nearly half a trillion dollars every year on prescription benefits. It’s a system that isn’t working for payers, members, or providers. It doesn’t need to be this way. We believe costs should be lower, hassles should be fewer, and the experience should be better. And with a smarter technology and a straightforward approach to business, we are ready to lead the way.