LOCATION: Remote – t his is a home based, virtual position that operates on US Eastern Standard Time within the hours of 8:30am-5:00pm. Vaya Health welcomes applications from NC, SC, GA, TN, VA, MD, and FL.

GENERAL STATEMENT OF JOB

As part of the Behavioral Health/Intellectual and Developmental Disability (BH I/DD) Tailored Plan adjudicates claims for behavioral health, physical health, and pharmacy services, to fully execute the requirements of the contract. While outpatient pharmacy claims are adjudicated through a Pharmacy Benefits Manager (PBM), Physician Administered Drug Program (PADP) medical claims adjudicate through the Vaya claims processing system (Conduent HSP).

The Pharmacy Operations Business Analyst role facilitates the technical and manual aspects of the Physician Administered Drug Program (PADP) program and Outpatient Pharmacy program. Importantly, the Business Analyst assists with review of reports and coordinates benefit change management to reduce the need for pharmacist resources and allow Vaya’s Pharmacy Director of NC Managed Medicaid Programs and VP of Pharmacy Services to focus on clinical analysis and overall plan management. Under the direct supervision of the Pharmacy Director of NC Managed Medicaid Programs, the Business Analyst works with Vaya’s Information Systems Division (ISD) in support of ISD efforts and resources related to pharmacy benefits management.

Additionally, the Business Analyst assesses and resolves day-to-day pharmacy operations needs, such as response file review and Lock-In Program, among others.

ESSENTIAL JOB FUNCTIONS

Encounters and Claims

• Weekly audit for PBM claims and encounters
• Benefits change management

Lock In

• Gather, compile, and analyze data necessary to publish monthly report
• Data entry into care management platform
• Draft provider and member facing communication

Response Files

• Monitor and ensure timely data exchanges between Vaya and its PBM
• Use business judgement to assess results and escalate as appropriate

Physician Administered Drug Program (medical claims for drugs)

• Review source data for necessary updates within the medical claims system
• Use business judgement to assess updates, communicate with key stakeholders, and escalate as appropriate
• Work with claims system and clinical subject matter experts to implement necessary updates
• Track and report key performance indicators of PADP claims processing across systems
• Monitor claims for issues that require manual intervention

Other reporting and administrative needs.

KNOWLEDGE, SKILL & ABILITIES REQUIRED:

This position requires excellent verbal and written skills. Strong people skills are required to promote excellent communication with staff at all levels across the Vaya enterprise. This position requires skill in organizing workflow. Ability to analyze and interpret policy and procedural guidelines is necessary. Intermediate level Microsoft Office software proficiency is required. Additionally, it requires an interest in learning a wide variety of software packages, including drug information databases, medical claims processing systems, and Pharmacy Benefit Managers (PBM) systems.

Additional preferred KSAs preferred:

• Knowledge in processing claims for prescription drugs
• Awareness of pharmacy data
• Awareness of the software development life cycle (SDLC)
• Experience in developing processes to ensure appropriate and timely oversight of data processes
• Understanding of claims editing for medical and outpatient pharmacy claims

QUALIFICATIONS & EDUCATION REQUIREMENTS

Bachelor’s degree in Biology, chemistry, computer science, other science, or other technical degree required. Two years of experience in a technical or business analyst role.

A masters level degree or professional designation (MBA, MPH, etc) can substitute for experience.

PHYSICAL REQUIREMENTS:

• Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
• Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists, and fingers.
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
• Mental concentration is required in all aspects of work.

RESIDENCY REQUIREMENT: Must live in NC, SC, GA, TN, VA, MD, or FL.

SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.

DEADLINE FOR APPLICATION: Open Until Filled

APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/ .

Vaya Health is an equal opportunity employer.