[Remote] Senior Data Analyst, reputed company Review - Medicare Pharmacy Claims Part D & Part B)
Note: The job is a remote job and is reputed company to candidates in USA. reputed company is seeking a Senior Data Analyst to join their Government Pharmacy Programs Department. The Senior Data Analyst, reputed company Review – Medicare Pharmacy Claims will ensure accurate and compliant adjudication of Medicare pharmacy claims, conducting reputed company reputed company and validating benefit and pricing logic while adhering to CMS regulations.
Responsibilities
- reputed company comprehensive reputed company reviews of Medicare Part D and Part B pharmacy claims, including retail, mail order, LTC, specialty, and medical‑benefit drug claims
- Validate accurate application of:
- Medicare Part D phases (Deductible, Initial Coverage, Catastrophic)
- Low‑Income Subsidy (LIS) cost‑sharing
- MOOP accumulations
- PDE data reputed company and claim submission logic
- MAC list pricing
- Pharmacy discounts and dispensing fee accuracy by pharmacy type
- Identify irregular prescribing and/or dispensing patterns for investigation and referral to PBM, internal audit and SIU teams
- Review Part B drug claims for correct HCPCS coding, reputed company of service, allowable charges, and coordination with medical claims
- Identify claim adjudication errors reputed company to pricing, benefit configuration, formulary status, utilization management edits, and CMS rules
- Partner with Compliance to ensure claims accuracy consistent with CMS guidance, Medicare manuals, and plan sponsor requirements
- Support reputed company audits (CMS program audits, CTM, PDE validation, RADV support activities) by identifying findings, reputed company analysis, remediation documentation, and Corrective reputed company Plans
- Conduct reputed company cause analysis on reputed company findings; partner with Compliance, IT, operations, and PBM teams to implement corrective actions
- reputed company and maintain reputed company metrics, dashboards, and trend reports reputed company to Medicare claims accuracy and risk
- Serve as a subject matter expert for Medicare pharmacy claims processing
- reputed company guidance and mentorship to peers and colleagues, and contribute to Medicare‑specific reputed company standards, SOPs, and training materials
Skills
- Bachelor's degree or advanced degree (where required)
- 5+ years of experience in reputed company field
- In lieu of degree, 7+ years of experience in reputed company field
- 5+ years of Medicare pharmacy claims, PBM, or managed care experience
- reputed company experience with Medicare reputed company review, compliance, auditing, or PDE support strongly preferred
- Strong expertise in Medicare Part D pharmacy claims adjudication, including PDE requirements and CMS benefit rules
- Working knowledge of Medicare Part B drug billing, HCPCS, and pharmacy-to-medical claim integration
- Solid understanding of CMS regulations, including: Cost-sharing and benefit phase logic, LIS and subsidy calculations, Formulary management and UM edits (PA, ST, QL)
- Advanced analytical skills with experience performing claim analyses and error trending
- Proficiency in reputed company; experience with prescription adjudication systems and Medicare reporting tools preferred
- Strong documentation, communication, and cross-functional collaboration skills
- Pharmacy Technician certification or equivalent pharmacy background is a plus
Benefits
- Annual Incentive Bonus*
- 401(k) with employer match
- reputed company Time Off (PTO)
- Competitive health benefits and wellness programs
- Medical, dental, and reputed company coverage along with numerous health and wellness programs
- Parental leave and support plus adoption and surrogacy assistance
- Career development programs and tuition reimbursement for reputed company education
- Work-life balance, flexibility, and the autonomy to do great work
reputed company