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Pharmacy Benefit Administration Analyst


  • What you’ll do
  • What you’re made of

In a few words…

Ah, yes, there are many benefits to being a Benefit Administration Analyst, and you’ll get to know them all intimately… In this role you’ll be responsible for implementing new benefit plan setups for Medicare Part D, Commercial and Employer clients. As BAA, you will review client benefit requests, identify and define their needs and requirements, determine best operational approach and perform setup in the PBM system. The position also requires that you perform client benefit setup testing as well as QA functions such as moving all plan benefit design implementations and/or changes into a Production scenario to ensure proper and accurate configuration for claims processing and adjudication. As BAA, you will overview operational issues, analyze and identify solutions to resolve issues in benefit setup, claims processing and other operational gaps, as well as identify process improvement opportunities to make benefit plan design setup more efficient. It wasn’t a lie when we mentioned many a benefit. It is used a total of 9 times in this paragraph alone.

The fundamentals for the job…

  • To warm up, you will process benefit plan setup for new Medicare, Commercial and Employer client implementations, and also process benefit changes for existing clients.
  • Monitor and analyze key data and procedures for proper claims processing and adjudication system functionality (i.e. eligibility management, benefit setup) for all clients.
  • Perform Quality Control and Quality Assurance functions to assess information accuracy in all Benefit Administration processes.
  • Provide timely support to other areas to verify and analyze claims processing cases, eligibility and other operational situations and/or issues referred for validation. (“Timely” is a favorite term for around here, since anything else is the same as “late”.)
  • Support urgent adjudication and processing issues including doing research, analysis, identification of root cause, impact analysis determination and corrective action.
  • Work cross-functionally to properly carry out changes, evaluate impact of new system requirements and assist in the design and execution of test scripts.
  • Help gather proper and accurate documentation and data during internal and external audits related to the Company’s PBM processes.
  • Process Drug Reimbursement requests (DMRs) for Commercial and Employer clients.
  • Manage the entire EOBs process for Medicare Part D and commercial clients, and ensure timely (you’ll get used to it, in timely) generation, validation and mailing. Also responsible for EOBs’ Quality Assurance.
  • Support Plan Finder file submissions by providing analysis and notifying in regards to any corrective action against potential issues.
  • Develop process documentation, including Policies and Procedures, to document Benefit Administration operational processes.
  • Stay current with Medicare Part D guidelines in order to make timely (see?) adjustments to operations ensuring our processes are in compliance with Medicare Part D’s rules and regulations.
  • Evaluate and analyze Benefit Administration process requirements to make recommendations for improvements.
  • All in all, the role requires putting your best foot forward for the benefit of all our processes. In a timely manner, for sure.

The bold requirements…

  • Associate or Bachelor’s Degree (preferred), and 2+ years of Medicare experience. (In lieu of a degree, equivalent relevant work experience may be considered.)
  • Computer proficiency (of course this is a must), knowledge of Microsoft Office products (you can at least stand your ground while using them), and Internet experience (who doesn’t know how to use the Internet expertly these days? Well, whoever they are, you definitely don’t fall within their ranks).
  • We’ll be very swayed (meaning it’s a big plus) if you already have a strong understanding of PBM Operations, Member Services, Pharmacy Networks, Fulfillment, Call Center, and Medicare Part D.
  • You’re great critical thinking (as befits an analyst of any stripe). You know what it means to be a “share the credit / take responsibility” worker. You ride change like an expert surfer rides waves. And let’s not forget your top-rated presentation skills!
  • Must be able to communicate effectively (read, write, speak, daydream, argue, flatter, retort wittily etc.) in English and Spanish.

That something extra we´d love to see…

  • Analytical: You value the power of context & enjoy examining the past. You get the present by analyzing (sometimes over-analyzing) events leading up to it. This methodology is super helpful, but can provoke analysis-fatigue in those within earshot. Good thing you’re aware of this.
  • Adapter: A responsive climate-switcher who is highly productive in a fast-paced environment. Practically shape-shifts to adjust to different situations.
  • Innovator: You constantly engender unexpected ideas; your factory of pure genius just doesn’t run out. Fascinated with possibilities you are, in turn, fascinating yourself. You plainly see or figure out connections between seemingly disparate phenomena, à la A beautiful mind. It is a child’s game to you.
  • Fixer / Problem solver: You like to provide comprehensive solutions, keeping in mind both internal and external needs. You keep with the mantra of always being part of the solution (not the precipitate). Those who precipitate, you’ve learned, repent at leisure
  • Responsible: You own what you say and what you do. Your word is your bond; you don’t let people down when you commit to something. You live by established values like honesty and loyalty but sometimes you can be a bit judgmental

The above description is not intended to limit the scope of the job or to exclude other duties not mentioned. It is absolutely not a final set of specifications for the position. It’s simply meant to give readers an idea of what the role entails.



Remote, OR
Posted: over a month ago