Medicare Part D Analyst Job Listing at CVS Caremark in Scottsdale, AZ

Healthcare, Retail

Job Category: Medicare
Clinical Licensure Required : N/A
Job Type: Full Time Position Summary:
The Analyst is responsible for providing technical and analytical support for Medicare Part D claims monitoring quality initiatives. The Analyst will be responsible for developing, documenting and executing a repeatable process to support claims reviews and prepare results summaries for Senior Management and client review. The process will involve defining detailed criteria for claims extracts based on various Medicare benefit set-ups and programs, performing claims reviews and reconciliation to establised standards and develop a process to remediate errors detected. The Analyst will work closely with the MPS Advisors and internal quality and compliance teams to ensure claims adjudication results meet defined regulatory standards. Take the lead role in providing system requirements and managing the projects with IT to implement system corrections if needed. This includes providing detailed system requirements and validating all IT documentation, including detailed test results and running post production validation queries to ensure the issue is corrected. Serve as a back up to SMEs on projects when required. Work independently as MPS SME on assigned regulatory projects when required. Manage technical or claim research questions from internal departments and clients. Run SQL queries or provide technical specifications to IT for data extracts when needed to resolve issues. Manage data manipulation and results reporting using Access and/or similar tools.

This position is responsible for validating that CVS Caremark is compliant with Federal Government (CMS) Medicare Part D regulations for claims adjudication (pricing, beneficiary cost accumulations, etc) Coordination of Benefits (COB), claims adjudication and benefit accumulations for Medicare Part D plans we service including Silverscript Insurance, Aetna and other large Med D Plans.
This individual will be responsible for assisting with Issue Log Items/Projects to ensure CMS Regulatory Requirements are successfully implemented on time across all functional business units impacted by the CMS mandated changes. Responsibilities include:

a. Identify and/or validate Issues that have reported to the Issue Log Team
b. Work with IT to help identify Root Cause analysis and Client Impact Analysis
c. Report to Issue Log Committee on the status of open/outstanding Issues
d. Facilitate and work with business parteners on any work around solutions that may be needed
e. Assist with drafting of client or member communications
e. Validate system fix after software enahancements have been implemented
f. Work with business partners on any clean up activites including any calls or letters to pharmacies or beneficiaries
g. Work with business parteners on any claims reprocessing initiatives

This position will also provide direct support to the Audit Team during CMS and/or client audits. The Analyst will review and analyze any claim examples that are provided by the Audit Team for intrepretation or clarification. Identification of adjudication issues will need to be triaged for resoultion via the Issue Log committee process outlined above. Required Qualifications:
At least three years of PBM, health care, health insurance or other insurance business knowledge required. Thorough understanding of Caremark claims adjudication system and related applications. Three years of technical experience including analyzing data from multiple sources and platforms. Experience with Medicare programs and any other governmentally regulated programs preferred. Must have intermediate/advanced knowledge in Microsoft Office suite with a focus on Excel, Access, PowerPoint, Word and Outlook skills. Data manipulation and report development experience required. Preferred Qualifications:
Ability to work with and influence crossfunctional to implement new requirements effectively - very strong interpersonal skills required. Ability to understand technical process flows and understand complex requirements. Requires the ability to understand complex mathmatical calculations and how plan design can impact Caremark's ability to meet CMS guidelines. Ability to "project manage" deliverables across multiple departments and follow-up to ensure completion. Ability to drive to solution quickly cross-functionally to meet CMS timeframes. Knowledge of Prescription Benefit Management industry Experience providing detailed system requirements and validating all IT documentation, including detailed test results. Knowledge of SQL, web and Access skills. Excellent verbal and written communication skills (be comfortable articulating complex issues to all levels of management). Ability to draft client or member communications to support Issue Log items/projects Excellent organizational and time management skills Excellent interpersonal and collaborative skills Able to work in fast paced and changing work environment with quick turnaround Able to work collaboratively with people in a team environment Able to work independently Requires attention to detail Ability to meet deadlines with a variety of responsibiliities Ability to work effectively with multiple functional areas Ability to exercise professional judgement in analyzing and resolving client issues Ability to creatively solve problems when dealing with a variety of variables in situations where standard resolutions do not exist Ability to thoroughly explain impacting results to internal and external clients Education:
Bachelor's degree required. An equivalent combination of education and experience may substitute. If no degree, two additional years of experience are required for each year of college not completed. Business Overview:
CVS Caremark, through our unmatched breadth of service offerings, is transforming the delivery of health care services in the U.S. We are an innovative, fast-growing company guided by values that focus on teamwork, integrity and respect for our colleagues and customers. What are we looking for in our colleagues? We seek fresh ideas, new perspectives, a diversity of experiences, and a dedication to service that will help us better meet the needs of the many people and businesses that rely on us each day.

As the nation’s largest pharmacy health care provider, we offer a wide range of exciting and fulfilling career opportunities across our three business units - MinuteClinic, pharmacy benefit management (PBM) and retail pharmacy. Our energetic and service-oriented colleagues work hard every day to make a positive difference in the lives of our customers.