Pharmacy Operations Business Analyst

Lets do great things together!

About Moda
Founded in Oregon in 1955 Moda is proud to be a company of real people committed to quality. Today like then were focused on building a better future for healthcare. That starts by offering outstanding coverage to our members compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places together. Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Lets be better together.

Position Summary
This is a FT hybrid position based in Portland. The Pharmacy Operations Business Analyst serves as the technical and analytical resource for Pharmacy Operations supporting the design validation monitoring and continuous improvement of pharmacy operational processes systems and vendor performance. The role is responsible for analyzing pharmacy claims validating benefit and formulary configuration supporting operational implementations developing reporting and monitoring tools and identifying opportunities to improve operational efficiency accuracy and regulatory compliance.

Working closely with Pharmacy Operations leadership Information Technology Account Management Compliance vendor partners and other business stakeholders the Pharmacy Operations Business Analyst performs complex operational analysis root cause investigations data validation configuration testing and system support across Commercial Exchange Medicare and Medicaid lines of business. The role plays a critical part in ensuring the accuracy of pharmacy benefit administration supporting CMS reporting and audit activities monitoring operational performance and implementing sustainable controls that improve quality and reduce operational risk.

Pay Range
$59922.05 - $74902.56 annually (depending on experience).
*Actual pay is based on qualifications. Applicants who do not exceed the minimum qualifications will only be eligible for the low end of the pay range.

Please fill out an application on our company page linked below to be considered for this position.

Dental Vision Pharmacy Life & Disability

Required Skills Experience & Education:

1. Bachelors degree or equivalent combination of education and relevant experience in healthcare administration business administration pharmacy information systems or a related field.
2. Five or more years of professional experience in pharmacy operations pharmacy benefit management health plan administration or a closely related healthcare environment.
3. Demonstrated knowledge of pharmacy benefit administration pharmacy claims processing benefit configuration formulary management prior authorization operations and operational workflows.
4. Experience analyzing complex operational data pharmacy claims system functionality and business processes to identify issues recommend solutions and improve operational performance.
5. Experience developing business requirements coordinating system testing validating system enhancements and supporting operational implementations.
6. Demonstrated knowledge of Commercial Exchange Medicare and Medicaid pharmacy operations and applicable regulatory environments.
7. Strong analytical problem-solving and root cause investigation skills with the ability to interpret complex operational and claims data
8. Demonstrated ability to manage multiple priorities work independently and successfully support concurrent operational initiatives.
9. Strong written verbal presentation and interpersonal communication skills with the ability to communicate effectively with both business and technical stakeholders.
10. Proficiency with Microsoft Office applications particularly Excel and experience working with pharmacy operational systems reporting tools or healthcare data platforms.
11. Demonstrated ability to develop documentation operational procedures business requirements and testing documentation.

Preferred Skills Experience & Education:

1. Experience supporting Medicare Part D operations CMS reporting audit activities or regulatory compliance initiatives.
2. Experience with PBM claims adjudication platforms pharmacy benefit configuration formulary management systems or prior authorization platforms.
3. Experience performing pharmacy claims analysis configuration validation benefit testing or operational monitoring.
4. Experience developing operational reporting dashboards data validation processes or performance monitoring tools using SQL Power BI Tableau or comparable reporting tools.
5. Experience supporting vendor oversight system implementations operational readiness activities or cross-functional process improvement initiatives.
6. Experience conducting root cause investigations and developing operational controls to improve quality compliance and operational performance.

Primary Functions:

Operational Analysis & Monitoring

• Analyze pharmacy claims operational data and system activity to identify trends operational issues and opportunities for improvement.
• Conduct root cause investigations for claims discrepancies operational issues configuration concerns and vendor-related incidents.
• Develop operational reporting dashboards and monitoring tools to measure performance identify emerging risks and support operational decision-making.
• Perform data validation and operational monitoring to ensure the accuracy and integrity of pharmacy operations across Commercial Exchange Medicare and Medicaid lines of business.

Pharmacy Systems Configuration & Testing

• Validate pharmacy benefit formulary network and prior authorization configuration to ensure accurate claims adjudication and operational performance.
• Coordinate and perform benefit formulary and system testing supporting new client implementations regulatory changes operational enhancements and vendor releases.
• Develop business requirements test plans test scenarios and validation documentation while tracking issues through resolution.
• Partner with internal stakeholders and vendor partners to evaluate system enhancements validate implementation outcomes and recommend operational improvements.

Medicare Operations Compliance & Vendor Oversight

• Support Medicare Part D operational activities including CMS reporting support operational monitoring audit readiness and regulatory compliance initiatives.
• Assist with internal and external audit activities through data validation issue analysis documentation and corrective action support.
• Monitor vendor operational performance validate deliverables investigate discrepancies and coordinate issue resolution with vendor partners.
• Develop and maintain operational controls that improve data integrity regulatory compliance and vendor accountability.

Process Improvement & Cross-Functional Support

• Identify opportunities to improve pharmacy operational processes through automation standardization enhanced reporting and monitoring.
• Develop and maintain business requirements operational procedures process documentation reporting specifications and technical documentation supporting pharmacy operations.
• Provide analytical support for new client implementations operational projects system enhancements and strategic initiatives.
• Collaborate with Pharmacy Operations Clinical Pharmacy Account Management Information Technology Compliance Customer Service and vendor partners to support operational excellence and continuous improvement.

Key Responsibilities

• Analyze pharmacy operational data to identify trends risks and opportunities for improvement.
• Perform claims analysis configuration validation and root cause investigations to support operational excellence.
• Develop reporting and monitoring solutions that improve operational visibility and oversight.
• Support operational implementations through requirements gathering testing validation and post-implementation analysis.
• Ensure the accuracy and integrity of pharmacy operational systems through ongoing monitoring testing and data validation.
• Collaborate with internal teams and vendor partners to improve operational performance and resolve complex business issues.
• Support regulatory compliance audit readiness and continuous process improvement initiatives.

Working Conditions & Contact with Others:

• Remote office environment and/or hybrid with extensive close PC and keyboard work and constant sitting. Work in excess of 40 hours per week including evenings and occasional weekends to meet business needs.
• Internally with Pharmacy Operations Clinical Pharmacy Account Management Information Technology Compliance Customer Service and other business departments and organizational leadership as required to support operational analysis system enhancements regulatory initiatives and continuous process improvement. Externally with PBM pharmacy technology and operational vendors and external business partners.
  

Together we can be more. We can be better.

Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race religion color age sex sexual orientation national origin marital status disability veteran status or any other status protected by law. This is applicable to all terms and conditions of employment including recruiting hiring placement promotion termination layoff recall transfer leaves of absences compensation and training.

For more information regarding accommodations please direct your questions to Kristy Nehler and Danielle Baker via our email.