Pharmacy and Quality Performance Analyst Denver Health Medical Plan (Must Be A Colorado Resident)

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Department

*Must Be A Colorado Resident

Job Summary

The Pharmacy Business and Quality Performance Analyst drives data-informed strategies to optimize pharmacy utilization improve care quality and promote cost-effectiveness across Medicare Medicaid and Exchange lines of business. Within a provider-owned health plan this role combines pharmacy operations and cost containment performance analytics and budget oversight to support Pharmacy Quality Improvement and Population Health departments. The analyst provides expert technical assistance to highly visible sensitive and multifaceted initiatives ensuring alignment with regulatory standards while advancing value-based care through actionable insights and collaborative program development.

Essential Functions:

• Pharmacy Analytics & Cost Containment
  Analyze pharmacy and medical pharmacy claims and utilization trends to identify cost drivers adherence gaps and savings opportunities
  Develop and maintain reporting tools to measure the financial and clinical impact (ROI) of utilization management strategies including prior authorization step therapy and formulary design; reports are shared with departmental leaders and presented to executive stakeholders
  Compile and reconcile pharmacy-related data submissions to CMS HPMS and State agenciesincluding attestations financial reports and encounter datato ensure accuracy and alignment with regulatory and organizational goals
  Create monitoring reports and dashboards to evaluate pharmacy program performance and identify opportunities for improvement across utilization cost containment and compliance initiatives
  Develop and maintain pharmacy reporting processes policies and procedures in alignment with State and Federal requirements or internal quality and reporting standards; ensure operationalization through documentation workflow integration and audit-ready reporting; proactively identify compliance gaps or performance issues and collaborate cross-functionally to implement data-driven solutions
  Support prescriber incentive programs to align clinical behavior with formulary and affordability goals
  Partner with PBMs and finance teams to develop cost containment models and optimize rebate strategies
  Ensure compliance with CMS State Medicaid ACA Exchange NCPDP and NCQA pharmacy-related requirements
  (60%)
• Quality Improvement & Population Health
  Build and maintain robust reporting systems to monitor performance across HEDIS CAHPS and CMS MCR Star Ratings including outreach reporting to track member engagement intervention effectiveness and closure of care gaps
  Analyze quality trends and identify performance improvement and cost saving opportunities across government-sponsored populations
  Evaluate gaps in care and support clinical interventions for chronic disease preventive services and medication adherence
  Support health equity initiatives through reporting and analytics including stratification of quality metrics and identification of disparities across populations
  Collaborate with Health Outcomes & Pharmacy leaders in QI and Population Health to improve performance under value-based contracts
  Assist with regulatory submissions audit support and accreditation readiness (e.g. NCQA)
  Support the evaluation of clinical and operational Performance Improvement Projects (PIPs) including tracking and assessing outcomes.
  Contribute data analysis and documentation support for Quality Assurance and Process Improvement (QAPI) and reporting for state and federal quality requirements.
  Analyze member experience and satisfaction trends to support quality interventions.
  Support Quality Committees with the preparation of data summaries and presentations.
  (25%)
• Business Budget & Operational Analysis
  Monitor external vendors analyzing data to ensure compliance with contractual requirements and performance expectations
  Conduct cost-benefit analyses and ROI evaluations for pharmacy and quality-related initiatives
  Translate complex analytics into insights and visualizations for operational and executive decision-making
  Support business case development and strategic planning across Medicare Medicaid and ACA Exchange lines
  Support the management of departmental budgets including forecasting tracking expenditures and analyzing financial variance
  Collaborate with actuarial finance and clinical teams on pharmacy and quality performance monitoring
  (15%)

Education:

• Bachelors degree in Pharmacy Public Health Health Administration Business Business Analysis Health Informatics Data Science Epidemiology Healthcare Economics Nursing or a related field required

Work Experience:

• 4-6 years healthcare analytics pharmacy services quality improvement or managed care operations required

Licenses:
Knowledge Skills and Abilities:

• Knowledge of formulary management utilization management CMS Star Ratings Medicaid quality metrics and value-based care models with demonstrated experience building reporting aligned to HEDIS and Star measure specification(s)
• Proficient in analytics tools such as SQL Excel Tableau or Power BI
• Familiarity with NCQA standards NCPDP requirements and actuarial or finance collaboration within managed care
• Ability to develop data requirements extract organize analyze interpret and communicate opportunities while working with operations teams and groups
• Ability to identify and define problems based on the collection of data establish facts and draw valid conclusions to present solutions.
• Demonstrates ability to manage multifaceted projects in conjunction with day-to-day activities.
• Excellent interpersonal and customer service skills ability to work collaboratively with other groups (such as Compliance Department product teams Finance Med-Econ and Information Systems) external vendors and State and Federal entities.
• Self-motivated and takes initiative: identifies acts on and documents solutions for gaps and opportunities for process improvements
• Critical thinking strong written and verbal communication skills and the ability to effectively interact within a team.
• Proven ability to interpret and synthesize Federal and State regulatory requirements ensuring policies procedures and processes are updated to comply with guidelines.
• Assists in monitoring of risk assessments preparation and compilation of audit requirements interprets audit results; monitors daily weekly and monthly reports.
• Knowledge of PC applications specifically Microsoft Office products and the ability to learn to computer applications involving Health Plan Management Software involving Claims Enrollment systems and Government Data Portals.

Shift

Work Type

Salary

Benefits

• Outstanding benefits including up to 27 paid days off per year immediate retirement plan employer contribution up to 9.5% and generous medical plans

• Free RTD EcoPass (public transportation)

• On-site employee fitness center and wellness classes

• Childcare discount programs & exclusive perks on large brands travel and more

• Tuition reimbursement & assistance

• Education & development opportunities including career pathways and coaching

• Professional clinical advancement program & shared governance

• Public Service Loan Forgiveness (PSLF) eligible employer free student loan coaching and assistance navigating the PSLF program

• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

Our Values

• Respect

• Belonging

• Accountability

• Transparency

All job applicants for safety-sensitive positions must pass a pre-employment drug test once a conditional offer of employment has been made.

Denver Health is an integrated high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center a 555-bed acute care medical center Denvers 911 emergency medical response system 10 family health centers 19 school-based health centers Rocky Mountain Poison & Drug Safety a Public Health Institute an HMO and The Denver Health Foundation.

As Colorados primary and essential safety-net institution Denver Health is a mission-driven organization that has provided billions in uncompensated care for the uninsured. Denver Health is viewed as an Anchor Institution for the community focusing on hiring and purchasing locally as applicable serving as a pillar for community needs and caring for more than 185000 individuals and 67000 children a year.

Located near downtown Denver Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.

Denver Health is an equal opportunity employer (EOE). We value the unique ideas talents and contributions reflective of the needs of our community.

Applicants will be considered until the position is filled.