Note: The job is a remote job and is open to candidates in USA. Blue Cross NC is seeking a Senior Data Analyst to join their Government Pharmacy Programs Department. The Senior Data Analyst, Quality Review – Medicare Pharmacy Claims will ensure accurate and compliant adjudication of Medicare pharmacy claims, conducting quality oversight and validating benefit and pricing logic while adhering to CMS regulations.
Responsibilities
- Perform comprehensive quality 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 elements 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, units of service, allowable charges, and coordination with medical claims
- Identify claim adjudication errors related 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 internal and external audits (CMS program audits, CTM, PDE validation, RADV support activities) by identifying findings, impact analysis, remediation documentation, and Corrective Action Plans
- Conduct root cause analysis on quality findings; partner with Compliance, IT, operations, and PBM teams to implement corrective actions
- Develop and maintain quality metrics, dashboards, and trend reports related to Medicare claims accuracy and risk
- Serve as a subject matter expert for Medicare pharmacy claims processing
- Provide guidance and mentorship to peers and colleagues, and contribute to Medicare‑specific quality standards, SOPs, and training materials
Skills
- Bachelor's degree or advanced degree (where required)
- 5+ years of experience in related field
- In lieu of degree, 7+ years of experience in related field
- 5+ years of Medicare pharmacy claims, PBM, or managed care experience
- Direct experience with Medicare quality 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 Excel; 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
- Paid Time Off (PTO)
- Competitive health benefits and wellness programs
- Medical, dental, and vision coverage along with numerous health and wellness programs
- Parental leave and support plus adoption and surrogacy assistance
- Career development programs and tuition reimbursement for continued education
- Work-life balance, flexibility, and the autonomy to do great work
Company Overview
It's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Health care is changing, and we're leading the way. It was founded in 1933, and is headquartered in Durham, North Carolina, USA, with a workforce of 5001-10000 employees. Its website is https://www.bluecrossnc.com/.